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Care Management Intervention May Provide Relief to Homebound Elderly

Dr. Martha Bruce. Photo Credit: John Abbott

A new care-management intervention developed by Weill Cornell Medical College investigators may provide relief to homebound older adults who suffer from moderate to severe depression.

The intervention trains nurses to both identify and manage clinically significant depressive symptoms. They do this by collaborating with the patient's physician to manage patients' anti-depressant adherence and side effects (nurses are not allowed to prescribe medications), provide a game plan designed to improve their symptoms — such as encouraging the patient to socialize and tend to their appearance — and educate their loved ones about their condition. Medical homecare nurses can integrate the technique into their routine practice and administer it while treating their patients for their primary medical conditions.

"The program provides nurses with a framework to deal with depression," said first author Dr. Martha Bruce, the DeWitt Wallace Senior Scholar and a professor of sociology in psychiatry at Weill Cornell. "It builds on their clinical skills and addresses nurses' observations that depression interferes with successful management of other medical problems."

The intervention could benefit more elderly, homebound people who need mental health services than are able to access them now. While older adults who are being treated at home for chronic diseases or physical disabilities are more likely to also have depression, a shortage of psychiatrically trained homecare nurses, compounded by the way Medicare covers care provided by such professionals, limits treatment options for affected patients, according to the study.

Dr. Bruce and her coauthors conducted a randomized clinical trial at six certified home-health agencies around the country to test the efficacy of the intervention, called Depression CAREPATH. Their study, published Nov. 10 in JAMA Internal Medicine, found that CAREPATH successfully relieved the symptoms of patients who have moderate to severe depression. The finding underscores the value of medical homecare nurses as care deliverers, as well as the need for improved homecare mental health services, Dr. Bruce said.

"We designed CAREPATH to reach as many patients as possible. We wanted something that would be effective but also flexible enough to fit in with different home-health organizations," Dr. Bruce said. "To put an intervention on top of an existing service is difficult since many agencies can’t afford the costs of sending an extra person to the home."

More than a quarter of all homebound patients receiving care through Medicare's home health program suffer from depression—a result consistent with the disability, chronic illnesses and other stresses that characterize the population — yet many don't receive mental health treatment. Medicare will typically only cover the cost of psychiatrically trained homecare nurses (a rare specialty) if patients' primary diagnosis is mental illness. Even if there are trained nurses available, Medicare's bundled payment schedule discourages home health agencies from authorizing extra home visits, Dr. Bruce said.

Working with researchers, homecare clinicians and administrators, Dr. Bruce and her colleagues developed CAREPATH to fill this void and mediate the financial and physical burdens that depression causes. CAREPATH provides nurses with instructions to follow given their patients’ depressive symptoms and a way to manage and identify their psychological state over time. Nurses can deliver the combination of approaches during their routine patient visits. The procedures are understandable and relatable to nurses, tapping into principles and terminology familiar to their practice.

Six home health agencies across the country piloted the program for the clinical trial, testing the effectiveness of CAREPATH compared to basic training to identify depression, but not on how to manage their symptoms.

During a regular homecare visit, nurses provided patients over 65 with a questionnaire gauging depression, with those identified as depressive receiving one of the two therapies on a randomized basis. The nurses treated them, and researchers conducted multiple follow-up interviews about their condition, for a year.

Dr. Bruce and her colleagues found that patients with more severe depression who were treated with CAREPATH had a more significant improvement in their conditions than those whose nurses had received basic training to identify depression. The outcome was the same whether or not patients were taking antidepressants, and did not require additional nurse visits or more nurse time in the home.

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