4. Mental Health Resources: It is helpful in case coordination and discharge planning if the agency catalogues the mental health resources available in the communities that serve their patients. Such resources include emergency psychiatric services, short-term interventions, and ongoing psychiatric care.
5. Develop Supervision Procedures: Because DCM is integrated into routine practice, agencies should ensure that clinical supervisors understand the protocol and include a review of its use as part of clinician supervision and evaluation.
After field testing the Depression CAREPATH with our local agency partners, it was implemented in collaboration with Community Health Care Services Foundation, Inc. and four home care agencies that were distributed across four regions of NY State (Hudson Valley, Northeast, NYC and Western). Across the four agencies, a randomly selected group of nurses from each agency (total N = 68) were trained in the full DCM protocol. Clinicians were eligible for the study if they were Registered Nurses and employed full or part time. Patients were eligible for the study if they were age = 65, newly admitted to home healthcare, and English-speaking. Exclusion criteria included chart diagnoses of dementia, bipolar disorder, or psychotic disorders. Effective use of the DCM protocol by participating clinicians was ensured via weekly telephone calls with nurse supervisors.
In consultation with the research team, the Project Leader at each of the agencies supervised the intervention nurses in the use of the DCM protocol. Using the protocol's PHQ-9 scores to document the course of depression from start of care to discharge, 50 (50%) of the patients with symptoms of major depression fully remitted (i.e., no longer depressed) and an additional 23 (23%) improved significantly (i.e., 50% reduction in depressive symptoms). The majority (52; 60%) of patients with symptoms of minor depression also improved. Although we have no direct comparison of PHQ-9 data from patients who did not receive DCM, we do know that these outcomes are consistent with results of depression treatment trials (Entsuah et al., 2001). Further, when we compared the discharge OASIS among DCM patients to 193 similarly depressed patients receiving usual care, usual care patients were 33% more likely to remain depressed than DCM patients. Although not definitive, these preliminary data suggest that the Depression CAREPATH Intervention contributes to positive outcomes.
The research team visited each agency at the close of the project to discuss the experience with DCM nurses and administrators. The overall response from nurses about use of the DCM protocol was positive. Nurses reported that the protocol fit well within routine care. One noted that it "helped me become a better advocate for my patients' care". Many found that it became easier to talk to physicians and mental health professionals about depressed patients. And they were more likely to ask family members about patient depression. The leadership was also positive; one administrator reported that she had added the training modules "to the orientation for all new employees." They all appreciated that nurses were trained to communicate with physicians more effectively, a skill that transcended depression care. Another administrator noted that the "project provided a role model for how nurses can integrate evidence-based practice into their routine work."
The high prevalence of depression in geriatric home healthcare patients poses a challenge to patients' outcomes and high-quality care. Depressed patients are less adherent to other treatment regimens, experience more adverse advents, and have poorer outcomes (Byers et al., 2008; Friedman et al., 2009; Katon et al., 2010; Sheeran et al., 2004; Sheeran et al., 2010). High levels of depressive symptoms are clinically significant whether or not a patient has received a formal depression diagnosis or is already taking antidepressant medication. Like other chronic medical conditions, depressed home healthcare patients will benefit from good DCM.
The Depression CAREPATH intervention was designed in collaboration with HHA clinicians and administrators for use in home healthcare in managing depression as part of ongoing care for medical and surgical patients. The intervention includes both a DCM protocol designed for use during regular home visits as well as implementation tools for HHAs.
Our group has demonstrated the feasibility of using the DCM protocol as part of routine care and of integrating it into six commercial software programs. Based on the feedback from these agencies and preliminary data, we are conducting an NIH-funded randomized trial to test the effectiveness of the Depression CAREPATH in seven agencies, located in different regions of the country. In addition, resources are being developed so that the tools needed to implement and support Cornell's Depression CAREPATH intervention will be freely and openly available to HHAs seeking to use the tools.
The authors express appreciation for the guidance and participation of partnering certified home healthcare agencies throughout the state of New York, including: Always There Home Care (Kingston), Americare CSS Home Health Care (New York City), Community Health Center (Johnston), Dominican Family Health Services (Ossining), Visiting Nurse Association of Central New York (Syracuse), Visiting Nurse Association of Hudson Valley (Tarrytown), and Visiting Nurse Services in Westchester (White Plains).
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