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Service Delivery Innovation Profile

Provider Training, Standardized Protocol, and Onsite Specialists Improve Diagnosis and Treatment of Depression in Older Adults in Rural Sites


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Snapshot

Summary

Project ADAPT (Assuring Depression Assessment and Proactive Treatment) tested a multifaceted intervention to improve the diagnosis and treatment of depression in older adults in rural (mostly primary care) sites. Under the program, providers received training, education, and ongoing consultation and support; agreed to use a standardized protocol for depression care; and designated an existing staff member as an onsite specialist who coordinated all depression-related care. The program enhanced access to screening and treatment and improved communication about depression among providers, leading to earlier diagnosis of the disease.

Evidence Rating (What is this?)

Suggestive: The evidence consists of analysis of post-implementation written surveys completed by 15 participating sites, along with findings from follow up interviews with these sites 3 months after the project's conclusion.
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Developing Organizations

Minnesota Area Geriatric Education Center; University of Minnesota Center on Aging
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Date First Implemented

2004
Project ADAPT was implemented from June to December of 2004.begin pp

Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Rural populations; Age > Senior adult (65-79 years)end pp

Problem Addressed

Although common, depression in older adults frequently remains undiagnosed, particularly among those in rural areas.
  • Prevalent among older adults: Depression is the most common emotional disorder among older adults and the most common risk factor for suicide in this population.1 Although they comprise only 12 percent of the population, people age 65 and older accounted for 16 percent of suicides in 2004.2
  • Often undiagnosed, especially in rural areas: Depression in older adults frequently goes undiagnosed, particularly in primary care settings, where most seniors receive care.3 Barriers to diagnosis in this setting include insufficient provider training, excessive focus on other common conditions (e.g., dementia) with similar symptoms, and the inaccurate belief that depression is a normal part of the aging process. Diagnosing depression in older adults living in rural settings is further complicated by a lack of professionals who are knowledgeable about assessing and treating mental illness, along with a general lack of mental health resources. Rural seniors may also be reluctant to discuss symptoms with their providers, fearing the social stigma associated with depression.1

What They Did

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Description of the Innovative Activity

Project ADAPT tested a multifaceted intervention to improve the diagnosis and treatment of depression in older adults in 44 rural (mostly primary care) sites. Under the program, providers received training, education, and ongoing consultation and support; used a standardized protocol for depression care; and designated an existing staff member as an onsite specialist who coordinated all depression-related care. Key elements of the program included the following:
  • Provider training and ongoing consultation: Project leaders conducted a 4-hour training session on depression in geriatric patients in three rural regions of Minnesota. Each session reviewed general information on depression in older adults, specific criteria for diagnosis and assessment, available treatment resources within the local community, and instructions on implementing ADAPT materials and strategies. Professionals representing 44 sites (including clinics, hospitals, long-term care facilities, public health and home care agencies, and county social service agencies) attended the sessions. After the training sessions, project leaders remained available to participating sites for consultation via phone, e-mail, and fax throughout the 6-month implementation period. The project coordinator also contacted each site at least twice during this time period.
  • Designated, onsite geriatric depression specialist: Each participating site chose an existing medical assistant, nurse, social worker, or psychologist to serve as an onsite geriatric depression specialist. The specialist coordinated all depression-related care for older adults, including conducting or assisting with screening, providing patient education, arranging treatment referrals, and conducting follow up inquiries. Although ADAPT leaders offered no formal training to the specialists beyond the sessions listed above, they provided guiding documents (listed below) and were available by telephone throughout the implementation period for technical support and problem-solving.
  • Standardized protocol for depression care: Participating sites agreed to use a standardized protocol for depression care that includes the following five components:
    • Screening: The geriatric depression specialist administers the short form of the Geriatric Depression Scale (also commonly known as the GDS-SF) to all patients aged 60 or older.
    • Assessment: The medical provider makes an assessment of depression for all patients scoring a 6 or higher (out of 15) on the scale.
    • Counseling: The medical provider (or geriatric depression specialist, if appropriately qualified) discusses the assessment findings, depression symptoms, and treatment options with the patient.
    • Treatment: The medical provider works with willing patients to develop a treatment plan. Possible treatment options include pharmacological and nonpharmacological options, as well as referrals to community mental health resources.
    • Followup: The medical provider and/or geriatric depression specialist maintains contact with each patient to monitor symptoms, adjust treatment, and offer ongoing support.
  • Supporting materials for patients and staff: Each participating site received a variety of materials designed to support program implementation, including depression criteria, assessment tools, the 15-item Geriatric Depression Scale in English and Spanish (along with instructions for its use), region-specific lists of available resources for referrals, treatment protocol forms, and recommended followup protocols. Sites also received educational materials to share with patients, including booklets and drug information (e.g., sheets on common side effects).

Context of the Innovation

Run by the University of Minnesota Center on Aging, the Minnesota Area Geriatric Education Center provides educational programs on a local and regional basis through partnerships with institutions and organizations involved in aging. Researchers at the center became interested in designing an intervention to serve rural Minnesota seniors not typically reached by the university's programs. To that end, they conducted a literature review, learning about Project IMPACT (Improving Mood/Promoting Access to Collaborative Treatment), a successful intervention that more than doubled the effectiveness of depression treatment in older adults by adding geriatric depression specialists to primary care clinics. The researchers decided to adapt this model for implementation in rural settings by using less highly trained staff already employed by the clinical sites to serve this role.

Did It Work?

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Results

The program enhanced access to screening and treatment and improved communication about depression among primary care providers, leading to earlier diagnosis of the disease.
  • Enhanced access to screening and treatment: Among 15 sites that responded to an anonymous written survey (mailed to all 44 participating sites), a total of 135 patients were screened for depression during the study period, with 59 being diagnosed with the disease. Among the seven sites that reported using the Geriatric Depression Scale without modifications, 63 patients received a positive score, with 45 patients subsequently being treated for depression. In the absence of this program, many of these patients likely would not have been screened or treated.
  • Better communication with providers: In a follow up telephone interview conducted 3 months after the 6-month project concluded, 8 of the 15 sites reported that the program led to improved communication about depression among primary care providers.
  • Earlier diagnosis: The same follow up telephone interview found that 8 of the 15 sites reported earlier identification of depression as a result of the program.

Evidence Rating (What is this?)

Suggestive: The evidence consists of analysis of post-implementation written surveys completed by 15 participating sites, along with findings from follow up interviews with these sites 3 months after the project's conclusion.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Forming interdisciplinary team: Project leaders formed an interdisciplinary team to develop and implement Project ADAPT. The team included a geriatrician, a geropsychiatric clinical nurse specialist, a pharmacist, a geriatric clinical social worker, and a project coordinator.
  • Consulting with Project IMPACT investigators: Members of the ADAPT interdisciplinary team met with Project IMPACT investigators to discuss how they might modify program strategies and materials. Team members also consulted with IMPACT investigators via telephone during the implementation process.
  • Developing educational materials: The ADAPT team developed professional and patient education materials to increase knowledge about geriatric depression, as described earlier. The team created a CD-ROM containing these materials, providing a copy to each participating site that could be reproduced and shared with colleagues.
  • Selecting target regions: The team chose three regions in Minnesota for project implementation, based on three key criteria: a rural designation, a significant population of older adults, and the presence of primary care clinics. Two selected regions were along the western edge of the state, with the third being in southeast Minnesota.
  • Recruiting sites: Staff from Minnesota Area Geriatric Education Center regional offices (called Regional Geriatric Education Centers) in the three target regions invited local providers to participate in Project ADAPT. Although the project was specifically designed for primary care clinics, significant interest from other settings led project staff to extend the invitation to hospitals, nursing facilities, home health care agencies, and other interested providers. They also published notices about the project in area newsletters and via e-mail through established mailing lists.

Resources Used and Skills Needed

  • Staffing: Key staff consisted of the five members of the interdisciplinary team (see Planning and Development Process above), including the deputy director of the University of Minnesota's Center on Aging, who served as the project coordinator. Team members worked part-time on the project. In addition, the regional coordinator at each participating Regional Geriatric Education Center spent significant time publicizing the project and recruiting site participants.
  • Costs: Project ADAPT operated for 6 months, with a budget of $108,000.
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Funding Sources

Health Resources and Services Administration
Project ADAPT was funded by a grant from the Health Resources and Services Administration.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Secure funding: Seek research grants that can provide the significant funding necessary to support a multidisciplinary team of specialists.
  • Work closely with local/regional staff: Use trusted local and/or regional staff to recruit providers and encourage their continued participation.
  • Ensure administrator buy-in: Without support from administration, individual providers and/or staff members have less incentive and ability to create any real changes to patient care.

Sustaining This Innovation

  • Consider focusing on one region: Conducting Project ADAPT in three separate rural areas made it difficult for project leaders to ensure that all participating providers implemented the care protocol thoroughly and consistently. Focusing the intervention on one region might allow project leaders to develop better relationships with providers and offer more assistance with problem-solving.
  • Tailor intervention to nonprimary care providers: Care protocols that work in primary care clinics may not work in other settings, such as long-term facilities and public health agencies. Would-be adopters of this program should examine the needs and capabilities of these types of sites and modify the program to better fit their existing care systems and processes.

More Information

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Contact the Innovator

Marilyn Luptak, PhD, MSW
JA Hartford Faculty Scholar in Geriatric Social Work
Assistant Professor
University of Utah College of Social Work
395 South 1500 East, GW Room 267
Salt Lake City, UT 84112-0260
Phone: (801) 581-3645
Fax: (801) 585-3219
E-mail: marilyn.luptak@socwk.utah.edu

Innovator Disclosures

Dr. Luptak has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

The Minnesota Area Geriatric Education Center Web site. Available at: http://www.coa.umn.edu/MAGEC/index.htm.

Luptak M, Kaas MJ, Artz M, et al. Project ADAPT: a program to assess depression and provide proactive treatment in rural areas. Gerontologist. 2008;48(4):542-8. [PubMed]

Footnotes

1 Luptak M, Kaas MJ, Artz M, et al. Project ADAPT: a program to assess depression and provide proactive treatment in rural areas. Gerontologist. 2008;48(4):542-8. [PubMed]
2 National Institute of Mental Health. Older adults: depression and suicide facts. April 2007. Available at: http://city.milwaukee.gov/ImageLibrary/User/jkamme/EAP/Info-Library
/MentalHealth_OlderAdultsDepres.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
3 Charney DS, Reynolds CF 3rd, Lewis L, et al. Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life. Arch Gen Psychiatry. 2003;60(7):664-72. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: November 25, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: December 03, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: October 24, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.