Lessons Learned from Using Depression Screening Measures

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Lessons Learned from Using Depression Screening
Measures

• Nancy L. Wilson, LCSW
• Department of Medicine-Geriatrics
• Huffington Center on Aging
• Houston Center for Quality Care Utilization
  Studies
• Baylor College of Medicine
• Care for Elders
• Houston, TX

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Ties not Roots not Missouri experts

• East St. Louis Kentucky farm refugees
• Cape Girardeau TV mecca
• St. Louis Cardinals (Remember 1964 !)
• Washington University consumer
• St. Louis University Alixe a graduate
• Recently Transformation Believer--
• Lots to learn..

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HEALTHY IDEAS
Identifying Depression Empowering Activities
for Seniors
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Accomplished through Partnerships

• Program Leadership Care for Elders and Baylor
• 80 member Houston-based partnership committed to
  creating solutions to increase access to
  services, improve quality and enhance life for
  older adults and caregivers
• www.careforelders.org
• Funders John A. Hartford Foundation,
  Administration on Aging, Robert Wood Johnson,
  SAMHSA
• Policy Leadership AoA , National Council on
  Aging
• Academic Expertise Baylor College of Medicine
  and Michael E. DeBakey Veterans Affairs Medical
  Center
• Community Aging and Mental Health Providers
• Elders and family caregivers

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Alixe McNeill, MPAVice President, Program
Development Mental Health Lead / Center for
Healthy Agingalixe.mcneill_at_ncoa.org

• Chair, National Coalition on Mental Health
  Aging

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National Council on Aging

• NCOAs Mission
• To improve the lives of older Americans.
• Who We Are
• NCOA is a non-profit service and advocacy
  organization based in Washington, DC.
• Visit www.ncoa.org

NCOA Core Values Social and Economic
Justice Respect and Caring Innovation Integrity
and Excellence
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National Council on Aging

• What We Do
• NCOA is a national voice for older adults
  especially those who are vulnerable and
  disadvantaged -- and the community organizations
  that serve them.
• NCOA brings together non-profit organizations,
  businesses and government to develop creative
  solutions that improve the lives of all older
  adults.
• NCOA works with thousands of organizations across
  the country to help seniors live independently,
  find jobs and benefits, improve their health,
  live independently and remain active in their
  communities.

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Todays Presentation

• Late-Life Depression
• Rationale for Community Action
• Origins and Key components of Healthy IDEAS
• Process of Implementation Funding ,
  Partnerships, Steps
• Training and Technical Assistance
• Views from Stakeholders

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Symptoms of Depression (DSM IV)

• Symptoms persist for two weeks or longer
• Depressed mood or an inability to enjoy life
• Any four of the following seven criteria must be
  present
• Change in sleep
• Change in eating habits
• Low energy or fatigue
• Feeling of worthless or excessive guilty
• Restlessness or slowed-down movements
• Diminished ability to concentrate or think
• Thoughts of death or suicide

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Depression in Late Life

• Depression is a recurring, chronic illness.
• Older adults are often under-recognized
  Under-diagnosed older adults underreport and
  present somatically.
• Co-exists with other mental or physical
  illnesses, including dementia and drinking.
• Cultural diversity can affect the presentation of
  depression.

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Depression is Common, Costly, Disabling, and
Deadly

• Depression affects 15-20 of older adults
• Depression is Disabling
• 2 cause of disability (WHO)
• Impact on Self-Care ADLs and IADLs
• Deadly and Reduced Quality of Life
• Suicide Elderly at greatest risk
• Co-morbid illnesses Affected Diabetes, Heart
  Disease
• Costly
• Expensive (50-100 higher health care costs)
• Increased Morbidity, Mortality, Non-adherence,
  recovery

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• PUBLIC HEALTH
• Increase awareness / reduce stigma
• Eliminate health disparities
• Improve access to services
• http//www.cdc.gov/aging/

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Setting Priorities for Older Adults

• Improving Access
• Integration of Mental Health and General Health
  Care
• Home and Community-based Services
• Improving Quality
• Evidence-based Practice Implementation
• Trained Healthcare Workforce with Expertise in
  Geriatrics

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Depression

• Major depression is second only to heart disease
  in the magnitude of disease burden..
• Mental Health Report of the Surgeon General
• Loneliness, isolation, limited resources and
  physical disabilities increase the risk of
  depression in older adults.
• Substance Abuse and Mental Health Among Older
  Americans The State of the Knowledge and Future
  Directions

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Community agencies reach high-risk, underserved
older adults
PRIOR HISTORY
ILLNESS/ DISABILITY
FEMALE
FAMILY HISTORY
RISK FACTORS
SOCIAL ISOLATION
LOSS
FINANCIAL STRAIN
IMMIGRANTS
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What we Know

• Health Disparities are significant
• Proactive Identification of depression is
  critical but not sufficient.
• Effective methods to identify, evaluate, treat
  depression and improve quality of life are
  available.
• Strong evidence depression care management and
  cognitive behavioral therapy approaches.

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Barriers to Addressing Depression in Older Adults

• Client Barriers
• Stigma Im not crazy! Im not a weak person
• Lack of knowledge- Its just my diabetes or
  being old What will this pill do?
• Provider Barriers
• Lack of knowledge and skills
• Primary Care faces many competing demands
• Scarcity of mental health professionals
• System Barriers
• How can we get care to the person or the person
  to care?
• Financing of services is limited and in silos

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Client Barriers Labels and Stigma
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Why address depression within community agencies?

• Reaching high-risk population
• Established rapport-cultural and linguistic
  competence
• Often already asking information on medication,
  health-co-occurring issues
• Existing focus on well-being and linkages with
  medical and community resources

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What is Healthy IDEAS?
Healthy IDEAS (Identifying Depression, Empowering
Activities for Seniors)

• An evidence-based community depression program
  designed to detect and reduce the severity of
  depressive symptoms in older adults with chronic
  health conditions and functional limitations
  through existing community based case management
  services.

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Program Goals

• Identify and address depression in older adults.
• Reach the intended population of frail, high-risk
  elders, who are often overlooked and
  under-treated.
• Train agency staff to provide and deliver an
  evidence-based depression intervention.
• Improve the linkage between community aging
  service providers and health care professionals
  through appropriate referrals, better
  communication effective partnerships.
• Prevent recurrence of depression through regular
  ongoing depression screening.

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Evidence-based Programs

• Outcome focused
• Track social, mental, physical functional
  changes using objective self reported measures
• Answers the question Can we do what is known to
  work?
• Monitors fidelity
• Moves science to service

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Anatomy of Evidence-based Programs

• Has a specific target population
• Has specific, measurable goal(s)
• Has a stated reasoning behind it and proven
  benefits
• Has an organized, well-defined program structure
  and timeframe
• Specifies staffing needs/skills
• Specifies tools and resources
• Builds in program evaluation to measure program
  quality and health outcomes

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Healthy IDEAS is an Evidence-based
Program

• Science to Service
• Used an approach translated from specific
  scientific random controlled positive research.
• Combines evidence-based components from other
  depression interventions including these major
  depression studies
• PEARLS AND IMPACT
• Retains the key elements of the programs to
  ensure known evidence-based ingredients remain
  (Fidelity).

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Evidence for Depression Care Management

• IMPACT (Improving Mood-Promoting Access to
  Collaborative Treatment). Unützer, J., Katon,
  W., Callahan, C.M., and J.W. Williams, Jr., et
  al. (2002). Collaborative care management of
  late-life depression in the primary care setting
  A randomized controlled trial. JAMA
  288(22)2836-2845.
• PEARLS (Program to Encourage Active, Rewarding
  Lives for Seniors). Ciechanowski, P., Wagner,
  E., Schmaling, K., Schwarz, S., Williams, B.,
  Diehr, P., Kulzer, J., Gray, S., Collier, C., and
  LoGerfo, J. (2004) 291(13)1569-77.
  Community-integrated home-based depression
  treatment in the elderly A randomized controlled
  trial. Journal of the American Medical
  Association 291(13)1569-77.

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Evidence for Healthy IDEAS Components

• IMPACT AND PEARLS offered the care management
  road map and evidence for in-home approach
• Evidence indicates that home-based mental health
  treatment for older adults is effective in
  improving psychiatric symptoms (Van Citters
  Bartels, S , 2004)
• Screening and Assessment Early recognition of
  depression facilitates treatment and can be done
  by non-professionals using valid tools. (Whooley
  et al. 1997, Sheikh Yesavage, 1986, Williams et
  al. 2002.)
• Education, Linkage, and Self-management Support
  (Unützer et al.,2002 and Hunkeler et al., 2000.)
• Behavioral Activation Helping clients
  activate to increase behaviors that fit with
  life goals and produce rewards will help decrease
  depressive symptoms. (Hopko et al.,2003,,
  Jacobson et al., 2000.)

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Target Population

• Underserved Populations
• Ethnically diverse and socio-economically diverse
  populations of older adults who are at high risk
  for depressive symptoms and living in the
  community.
• Inclusion Criteria
• 60
• Currently enrolled in a care or case
  management program
• Cognitive ability to participate
• Able to communicate verbally

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Program Design

• Embedded in case management programs.
• Case managers visit clients in their home and do
  telephone follow-up as well in the community
  individually over a 3-6 month period.
• A manual outlines the steps and includes written
  worksheets, client handouts, and forms to support
  and document the steps and client outcomes. (
  SEE Guide Handout)
• Community partnership approach for training,
  evaluation fidelity.
• Partner with health mental health care
  providers to facilitate referral.

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Core Program Components

• Screening for symptoms of depression assessing
  severity
• Two-question screen standardized assessment
• 15 item Geriatric Depression Scale (GDS) or PHQ-9
• Educating older adults family caregivers about
  depression effective treatment including
  self-care medication.
• Referral, linkage follow-up for older adults
  with untreated depression to health or mental
  health providers.
• Behavioral Activation (BA) empowering older
  adults to manage their depressive symptoms by
  engaging in meaningful, positive activities.

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Behavioral Model of Depression
Depression results in behaviors that limit
positive outcomes ? reduced pleasure, reduced
accomplishment
Lowered Mood
Decreased Activity
Decreased Pleasant Activities
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Behavioral Activation

• Improve mood by
• Increasing frequency of behaviors that lead to
  positive outcomes
• Doing activities that feel good or are
  pleasurable or reduce stress (may involve a task,
  something social or an activity)

           
Rewarding Activities
 
  Decreased Depressive Symptoms
  Improved Mood
        .
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Evaluation Design

• Pre-post impact evaluation data collected.
• Measures were embedded into agency assessment
  care plan review forms.
• Data collection occurs according to the routine
  timeline for case management Baseline, 3 months,
  6 months, and for some clients 9 months
  assessment.
• Outcomes address
• Depression, pain, social function, social and
  physical activity levels, education/knowledge,
  service use
• Measured client satisfaction via telephone
  interviews.

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Client Demographic Profile
p.05, p01, p.001, p.0001
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Delivery Experience and Outcomes

• Older adults vary in their readiness to address
  depression
• Most elders prefer treatment through primary
  care others accept mental health services
• Increased participation in BA associated with
  better outcomes
• Medication Use is common, yet not always
  effective

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Client Impact

• Reduction in depression severity
• Reduction of self-reported pain
• Increased knowledge of how to get help for
  depression.
• Increased level of activity
• knowledge of how to manage
  depressive symptoms.

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GDS Outcomes (15 item scale)
Scores at 3 and 6 months differ from baseline at
p lt .0001
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Clients Reporting Pain
Scores comparing Baseline to 6 months differ at p
lt .005
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Agency Impact

• Staff are trained to deliver an evidence-based
  intervention
• Adds credibility to the work
• Case management services are expanded to include
  mental health
• OK to talk about take action
  on Depression
• I was surprised that my clients
  were not
  only willing to talk about their
  mood but chose to
  do something.
• What seemed like a small step to me
  helped my
  client feel successful

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Community Impact

• Reached under-served populations
• low-income, physically frail, ethnic and
  racial minorities
• Improved linkage between community aging service
  providers and health /mental health professionals
  
• Fostered community academic partnerships
• Helped prevent recurrence of depression

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Miss Grace

• 68 year old single woman, lives with her brother
  who has Alzheimers disease.
• Initial geriatric depression score 8/15
• Client encouraged to do something she enjoys -
  both client her brother were professional
  artists.
• First step spend 30 minutes 1X a week sketching.
  
• Goal increase the time she spent painting
• She now paints or draws almost daily. Her brother
  has also begun drawing again
• Follow-up GDS at 90 days 6/15

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Common Worries in the Beginning

• How do I Its hard to go from meals to mood?
• How will I ever find the time to do this and
  everything else?
• What if my client doesnt want to talk about
  this?? OR
• Wants to talk too much??

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Where is Healthy IDEAS? 50 Sites

• States
• Arizona
• Florida
• Georgia
• Hawaii
• Iowa
• Maine
• Maryland
• Michigan
• New Jersey
• Ohio
• Texas
• Vermont

• Organizations
• Area Agency on Aging case management programs
• Local non-profit social service agencies
• Behavioral health provider agencies
• Caregiver support programs

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Maine Experience

• Lead Elder Independence of Maine
• - an Area Agency on Aging and home care
  coordination agency
• Statewide rural and urban
• Funding OAA Medicaid HCBS Waiver
• Case Managers BAs, LSWs, RNs
• Clients Caucasian, education high school or
  less, low-income

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Fort Worth, Texas Experience

• Lead Area Agency on Aging of Tarrant County and
  United Way
• Urban County
• Collaborative Model with agencies linked -
  Catholic Charities, Meals on Wheels, Senior
  Service, Mental Health Association
• Funding OAA built into agency financing
• Case Managers BAs, LSWs
• Clients African Amer. Hispanic, Caucasian

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Ohio Experience

• Lead State Mental Health with Aging and
  Substance Abuse
• Statewide urban and rural
• Model Older Ohioans Behavioral Health Network
  leadership local AAAs and county MH partners
• Funding SAMHSA MH Transformation Funds/
• mini grants to local AAA agencies
  (Integrated CM for Medicaid and OAA funded
  services )
• Case Managers BAs, LSWs, RNs
• Clients African Amer., Hispanic, Caucasian

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Other Experience

• Florida
• Local health foundation
• 3 lead agencies, 80 minority populations
• New Jersey
• State Aging OAA grants to Jewish Family Services,
  Medicaid HCBS waiver, MSWs
• Hawaii
• Lifespan Community family service provider to
  Asian and minority populations, BAs,

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Lessons Learned

• Various lead and provider agencies
• Success in urban and rural areas
• Success with racially and ethnically diverse
  groups many low-income
• Variety in start-up funding
• Embed practice for sustainability

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Steps for Implementation

• Healthy IDEAS Readiness Assessment
• Leadership Team Partnership Development
• Staff Selection
• Program Installation
• Pre-Service and In-Service Training
• Consultation and Coaching
• Program Evaluation

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1. Healthy IDEAS Readiness Assessment

• Online survey from NCOA and Healthy IDEAS
• Assesses agency capacity and willingness to
  implement Healthy IDEAS by measuring key program
  elements
• Staffing
• Partnerships
• Case Management Practice
• Record Keeping and Reporting Systems
• Organizational Culture and Support
• Program Leadership
• Innovativeness
• Evidence-based Experience

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Readiness Report Grid
Graphic representation of a potential adopter
organizations readiness status in terms of each
critical element of an innovative program
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2. Leadership Team Partnership Development

• Healthy IDEAS is an important process of
  organizational change requiring leadership and
  time of 2-6 months.
• Leaders identify, mobilize and unite strengths of
  expertise in aging and mental health services
  within and outside lead agency
• Establish partnerships for program collaboration
  and referral

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3. Staff Selection

• Leadership and Management
• With Champion(s)
• Trainer (s) and Coaches
• Clinical Consultant
• Case Managers / Frontline Providers
  Supervisors

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4. Program Installation

• Plan for embedding Healthy IDEAS into current
  delivery system of case management (or other
  service)
• Establish policies and procedures for
  implementation
• Customize tools and forms
• Arrange for training and technical assistance

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5. Pre-Service In-Service Training

• Initial education about depression
• Interactive training
• Ongoing coaching / supervision

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6. Consultation and Coaching

• Goals
• 1. Support case managers in developing
  confidence /skills to deliver program
• 2. Assure adherence and competence to conduct
  program
• Ideally - Train clinically qualified agency
  supervisors or program director
• Observe, review records, confer, advise
• Supervisor evaluates case managers

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7. Program Evaluation

• Collaborate in evaluation plan development
• Insure agency needs are met
• Use menu to select basic process outcome
  measures to be collected
• Embed data collection in routine forms, and
  systems
• Promote Continuous Quality Improvement

57
Key Steps in Program Implementation

• Identifying Resources
• Building the Right Team
• Installing the Program
• Training and Coaching
• Evaluation for Continuous Quality Improvement and
  Monitoring Fidelity

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Implementation Process Activities and
Resources

• Agencies or Community Partnerships need
• Dedicated program leadership Champion,
  Supervisors
• Mental/Behavioral Health Expertise for
  Training/Coaching
• Effective Linkage Communication systems with
  Treatment Providers
• Practitioners with capacity/ability to
  incorporate components into their existing case
  management routine with older adults/caregivers
• System for collecting and monitoring depression
  and other relevant outcome data

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Healthy IDEAS Replication

• Tools for assessing organizational readiness
• Plan includes approach and tools for each core
  component
• Technical Assistance via telephone consultation
  as your team develops local plans

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Training tools and resources that process
evaluation lessons from early adopters Agency and
Intervention Manuals role descriptions, fidelity
tools
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Once Program Installation Tasks are Complete

• Training
• Depression 101 from local professional (s)
• National Intervention Team Training
• Involves local leaders and coaches
• Conducted over two days 5.5. to 6 hours
• Based on established curriculum using
  training DVD

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What does Implementation Look like ?

• Key Agency Readiness TasksCollaboration with
  community mental health experts to assist with
• Training of care managers and supervisors
• Linkages to evaluation and treatment resources
• Organizational Staff Readiness for Change
• Internal advocate/cheerleader
• Training and Follow-up Coaching and Supervision

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Challenges

• Stigma among clients and providers
• Reluctance to change Clients and staff both
  have to learn new behaviors
• Resources - Affordable mental health diagnostic
  or treatment services
• Time required for the intervention in the face
  of competing demands
• Commitment at the agency level to addressing
  depression and supporting a change process.

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What might you expect?

• 15-40 of clients are positive for depressive
  symptoms
• 15-35 are taking an antidepressant already-
• Clients embrace self-care tasks to varying
  degrees-not all will set behavior change goals
  initially, some never

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Healthy IDEAS Tries to..

• Build knowledge and awareness of depressive
  symptoms
• Enhance motivation to take action
• Teach and support skill use in daily life
• Increase opportunities and resources for
  successful skill use to achieve better outcomes.

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For More Information

• Quijano, L.M., Stanley, M.A., Petersen, N.J.,
  Casado, B.L., Steinberg, E.H., Cully, J.A.,
  Wilson, N.L. Healthy IDEAS A depression
  intervention delivered by community-based case
  managers serving older adults. (2007) Journal of
  Applied Gerontology 26139-156.
• Casado, B. L., Quijano, L.M., Stanley, M.A.,
  Cully, J.A., Steinberg, E.H., Wilson, N.L Healthy
  IDEAS Implementation of A Depression Program
  Through Community-Based Case Management. (in
  press) The Gerontologist.
• Replication report NCOA-Center for Healthy Aging
  website http//www.healthyagingprograms.org
• Care for Elders www.careforelders.org/healthyide
  as

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• What Do Key Stakeholders Say About Healthy
  IDEAS?

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Administrators Say

• We see depression with isolated people.
  Depression is part of the problem stopping
  healthy behavior. If we want to help people
  remain in their own homes with high quality of
  life, we need to address depression and make this
  part of our services.
• Since we have ongoing training for case managers,
  we could integrate depression care into the
  broader program - it would be great to do this.
  
• Before we started Healthy IDEAS, we did not have
  the tools to work with clients on depression, now
  we have a concrete program that we can use to
  truly assist clients.

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Funders

• AoA supports Healthy IDEAS in its Evidence-Based
  Disease and Disability Prevention Program
• SAMHSA gave Healthy IDEAS a Science Service
  Award
• Federal, state foundation funders set goals
• Within 10 years, national reach will be achieved
  with effective community depression care programs
  like Healthy IDEAS and PEARLS.
• Programs will be high quality, have fidelity and
  be implemented in sustainable ways through strong
  and effective partnerships.

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Case Managers Say

• One-third of my caseload shows symptoms of
  depression, it is an important issue to address.
  
• It was hard to add one more thingbut seeing
  our clients respond ...this is worthwhilewe are
  actually empowering them.
• With Healthy IDEAS case managers are now able to
  offer resources that assist our clients in
  self-management of depressive symptoms. This
  allows us to better serve our clients.
• I have seen big changes with clients
  participating in Healthy IDEAS including
  increased mobility.

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Clients Say

• With the information I have now, I am better
  able to manage my health.
• I enjoyed doing activities that made my day seem
  better.
• I understand how my activity affects my mood
  now. When I am feeling sad, I go for a walk or
  go out to the local grocery store and I just feel
  better.

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Taking Action Individual or Agency

• Take a few minutes to identify what one thing you
  can undertake to
• Improve depression care for elders in your
  community
• Maintain a positive, healthy mood in your own life

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How can your agency explore addressing
depression?

• Examine how other communities in state or nation
  are addressing depression
• Compile data about current depressive symptoms,
  unmet needs in current clients
• Conduct dialogue with key partners outside your
  agency (aging, health, mh)
• Consider how to mobilize existing funds or
  donated resources to do a program