Counselor-Led House Calls Reduce Symptoms and Hospitalizations, Improve Quality of Life Among Home-Bound Elders With Mild Depression

Problem Addressed

• A common problem among the elderly: Nearly 5 million of the 31 million Americans aged 65 and older are clinically depressed, with 1 million having major depression.¹ In studies where primary care practices systematically screen for depression, between 17 to 37 percent of elderly patients have been diagnosed with the disease.¹ 
• Often undiagnosed: While elders who are socially isolated, homebound, or have multiple chronic health conditions are at high risk of depression, primary care providers often fail to diagnose depression in these patients, especially when the condition is not severe.² Health professionals may mistakenly think that depression is an acceptable response to the medical, social, and financial challenges that accompany aging.³ Older patients often do not report depressed moods, dismissing them as a natural part of aging or living alone, and instead report vague symptoms such as insomnia, anorexia, and fatigue to providers (who do not associate these symptoms with depression). 
• Difficult to access treatment when diagnosed: When depression is diagnosed, seniors—especially those who are homebound with low-incomes—struggle to access mental health services, which are often not available at their primary care provider’s office. In-home delivery of psychotherapy can greatly increase access to these services, but few home visitation programs provide mental health services.
• Leading to negative impact on quality of life, high costs: Untreated depression in the elderly impairs physical functioning, response to medical treatment, and quality of life, and can lead to more frequent hospitalizations and ED visits. The direct and indirect costs of depression are $43 billion annually in the United States.¹

Description of the Innovative Activity

• Initial referral: PEARLS serves older adults with minor depression or dysthymia who have previously qualified for comprehensive home visitation services. Clients may be referred by case managers working within the Area Agency on Aging, other social service or public housing programs serving the elderly, primary care providers, or self-referrals by clients. Most clients have multiple chronic illnesses such as diabetes, heart failure, and coronary, artery, lung and/or kidney diseases.
• Screening and enrollment: The agency uses the nine-item Patient Health Questionnaire to screen clients for depression. The depression screen is administered again at the end of the program to track changes in depression scores.
• Home visits: Clients receive 8, 50-minute in-home sessions over a 19-week period (weeks 1, 2, 3, 5, 7, 11, 15, and 19). Home visits allow the counselor to evaluate the clients' mental health by observing and experiencing their home environments. Longer sessions at the end of the program provide more time to practice problem-solving skills. Counselors do not perform general case management functions with the PEARLS clients, so as to keep those roles separate. Key aspects of the visits are described below:
  • Problem-solving approach: Counselors focus on problem solving, using a seven-step approach to help participants identify and solve problems. Many elderly individuals feel overwhelmed by unsolved problems, which contributes to their depression. Helping them solve those problems can reduce (and sometimes eliminate) depressive symptoms. The steps include clarifying and defining a problem, setting realistic goals, generating multiple solutions, evaluating solutions, selecting a feasible one, implementing it, and evaluating the outcome. During each session, the participant identifies a problem and works through these steps with the therapist’s support. During the next session, the pair evaluates the effectiveness of the solution and then identifies and addresses another problem.
  • Participant-driven: The client selects both the problem and solution, which creates a sense of empowerment for participants. Commonly selected goals include improving medical conditions (e.g., relieving chronic arthritis pain), improving relationships with peers and family members, and addressing financial concerns, social isolation, and housing-related issues.
• Social and physical activation: Because increased activity leads to decreased depression, therapists work with participants to develop a program appropriate for their physical capabilities and preferences, and encourage them to use community resources such as senior centers, exercise classes in housing units or parks and recreational programs, and church based activities. Activities may be as simple as going out to get the mail (rather than relying on a caregiver to do so) or lifting soup cans for 20 repetitions. Counselors often encourage participants to engage in a pleasant activity (which has been shown to reduce the symptoms of depression), providing a list of more than 200 possible activities, such as gardening, looking at pictures of grandchildren, or taking a bath. The activities may involve other people or going places, or may be activities that clients can perform on their own.
• Clinical supervision: A psychiatrist (the program clinical supervisor) reviews all cases and discusses them with counselors at depression management team sessions that occur at least every other week. For patients who do not show continued improvement, the psychiatrist will contact the primary care physician to recommend additional treatment options. Each case requires roughly 10 minutes of review/discussion. 
• Followup: After the home visits end, counselors make 3 monthly phone calls to clients, during which they review problem-solving capabilities and administer another depression screen. During these calls, they urge participants to continue using the problem-solving approach and to increase outside activities.

References/Related Articles

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Results

• Significantly fewer symptoms: Forty-three percent of the 72 PEARLS clients experienced a 50 percent or greater decline in depression scores, signifying a significant reduction in symptoms, compared to just 15 percent of 66 clients who received usual care. Thirty-six percent of PEARLS participants experienced sufficient reduction in symptoms to no longer meet criteria for minor depression or dysthymia.
• Fewer hospitalizations: Twenty-seven percent of PEARLS recipients were hospitalized during the previous 6 months, compared to 35 percent of those receiving usual care. 
• Better quality of life and well-being: The program produced significant improvements in emotional and functional well-being, including greater acceptance of illness, greater enjoyment of recreational activities, and higher satisfaction in coping with chronic conditions. 
• Low drop-out rate: Fewer than 10 percent of participants dropped out of the program during the initial study, as most clients enjoyed having the therapists visit their home.
• No change in use of antidepressants: The percentage of patients taking antidepressants did not change significantly over the course of the intervention in either the control or PEARLS group.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Development of PEARLS model: Health Promotion Research Center researchers and faculty members developed the PEARLS model in partnership with managing, supervisory, and clinical staff at Aging and Disability Services (the Seattle/King County Area Agency on Aging) and Senior Services of Seattle/King County. This partnership enabled researchers to design the program to be integrated into the infrastructure and organization of local Area Agency on Aging home visitation programs.
• Staff training: The counselors received 2.5 days of training in the PEARLS model, with sessions led by staff at the Health Promotion Research Center.
• Ongoing monitoring: A data coordinator manages program data on an ongoing basis, including results from baseline and followup questionnaires. Other record keeping includes tracking and reporting the number of clients who have been referred, deemed eligible, enrolled, and completed the program. The coordinator also tracks program evaluations filled out by clients. 

Resources Used and Skills Needed

• Staffing: The Seattle Area Agency on Aging has approximately 50 case managers who refer depressed clients to 1.5 full-time-equivalent (FTE) PEARLS counselors who serve roughly 30 to 40 PEARLS clients at a time. (The maximum case load for each FTE therapist is about 25.) Current counselors have Masters-level degrees though bachelors-level therapists have been used elsewhere. The agency also contracts with a psychiatrist to provide 4 to 8 hours of clinical supervision to the counselors each month. In addition, an agency manager oversees the program. As noted, a part-time data coordinator manages program data on an ongoing basis.
• Costs: During the initial study, total costs averaged $630 per participant, including $422 for the home visits, $28 for followup calls, $12 for psychiatric supervision and telephone calls, $87 for psychotherapy quality assurance, and $81 for depression management team sessions. Training costs average roughly $500 per therapist.

Funding Sources

Centers for Disease Control and Prevention; Substance Abuse and Mental Health Services Administration (U.S.); Washington State Aging and Disability Services Administration

Tools and Other Resources

Getting Started with This Innovation

• Identify administrative champion: An administrative champion helps move the organization down the road towards adopting the PEARLS program and can help overcome initial concerns regarding necessary organizational changes required to begin the implementation process.
• Assemble implementation team: This team will implement PEARLS within the agency, utilizing existing staff or hiring additional therapists/counselors, appointing a clinical director to supervise the program, and establishing a protocol for case managers to refer potential clients to the program.
• Create recruitment, referral, and screening processes: Identify and approach social service agencies and public housing entities, primary care providers, clubs, and other organizations that may serve as referral sources. Determine which depression screening tools will be used to assess clients at program entry, during treatment, and at exit.
• Establish data collection system to assess program: Identify what data should be collected to evaluate the program's effectiveness on an ongoing basis. If possible, set up systems to track hospitalizations among clients before and after program participation so as to document the program's cost-savings potential.

Sustaining This Innovation

• Regularly evaluate enrollment to identify barriers: Assess enrollment numbers regularly to identify and address any internal or external barriers that impede referral of clients to the program.
• Share data on program impact: Evidence of a decline in symptoms and/or cost savings (through reductions in hospitalizations and/or ED visits) can be useful in encouraging would-be funders to support the program.  
• Adjust eligibility criteria as needed: If adequate capacity exists, consider admitting younger individuals and/or those with more severe symptoms of depression into the program.

Additional Considerations and Lessons

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