Download PEARLS - National Council on Aging

Prevention Research Centers (PRC)-Healthy Aging Research
Network (HAN) Webinar Series
Evidence-Based Depression Care
Management: Program to Encourage
Active, Rewarding Lives for Seniors
(PEARLS)
Moderated by: Sheryl Schwartz
Mark Snowden
Pamela Piering
Susy Favaro
Sponsors:
Prevention Research CentersHealthy Aging Research Network
http://www.prc-han.org/
Retirement Research Foundation
http://www.rrf.org/
National Council on Aging
http://ncoa.org/index.cfm
Community-Integrated HomeBased Depression Treatment for
the Elderly
Mark Snowden, MD, MPH
Associate Professor Dept. of Psychiatry
UW Health Promotion Research Center
Learning Objectives
• The clinical components of PEARLS
• The personnel involved in delivering PEARLS
• The target population of older adults most suitable
for PEARLS
• Outcomes that have been demonstrated in research
trials of PEARLS
• Challenges and strategies for overcoming the
challenges related to funding, client treatment and
program management
PEARLS Study Goals
• To develop a case-finding system for frail elderly
individuals with or at high risk for depression
• To develop a community-based depression
treatment program for physically impaired and
socially isolated older adults
• To use this system to recruit and randomize
participants comparing the treatment program with
usual care
Depression Care Management
Core Components
• Active Screening to identify depressed patients
• Measurement-based care
• Depression care manager (MSW,Ph D, RN)
• Supervising Psychiatrist
• Evidence Based Treatment
PEARLS Intervention
Conducted in the home of participants, in 8 sessions over
19 wks
• Active screening for depression
– PHQ-2 initially, now use CES-D-11
• Measurement-based outcomes
– PHQ-9
• Trained depression care manager
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–
–
–
–
Recruited from Agency Case managers
Problem Solving Treatment
Physical Activation (30 mins moderate activity 5D/wk)
Social Activation
Pleasant Events
PEARLS Intervention
• A supervising psychiatrist
– Eligibility questions
– PST supervision
– If necessary, recommendations for medication
management
– Management Suicidal Ideation
• Follow-up phone calls (1/month, for 3- 6 months)
Problem Solving Treatment
• Theory:
– Overwhelming, unsolved problems increase
depression
– Solving Problems decreases depression
• Patient Centered and Directed
• Skill building
Problem Solving Treatment
•
7 Steps
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–
–
–
–
–
–
Clarify and define the problem
Set realistic goals
Generate multiple solutions
Evaluate and compare solutions
Select a feasible solution
Implement the solution
Evaluate the outcome
PEARLS Participant Criteria
Inclusion:
• Age 60+
• Diagnosis of minor depression or dysthymic
disorder
• Recipient of services from Senior Services or
Aging & Disability Services, or resident of
public housing
Exclusion:
• Major depression and other psychiatric disorders
(e.g., bipolar disorder and psychotic disorder)
• Substance abuse
• Cognitive disorder
Diagnostic and Statistical Manual
Criteria: Minor Depression
1) Depressed Mood And/Or
2) Anhedonia
3) Anorexia/wt loss or Weight Gain
4) Insomnia or Hypersomnia
5) Psychomotor Agitation or Retardation
6) Fatigue
7) Feelings of Worthlessness/Guilt
8) Indecisiveness/Trouble Concentrating
9) Recurrent Thoughts of Death/Suicide
***2-4 of 9 symptoms >/= 2 wks***
Dysthymia
• Depressed more days than not at least 2yrs
• Two or more symptoms when depressed
• Never without symptoms more than 2 months
Recruitment of Study
Participants
• Agency referral
– 1,238  105 eligible
• Self-referral
– 181  45 eligible
– (marketing prospect)
Study Participant Demographics
Usual Care
(n=66)
Intervention
(n=77)
Total
(n=138)
50 (76%)
59 (82%)
109 (79%)
Average age
73.5
72.6
73.0
Living Alone
43 (65%)
56 (78%)
99 (72%)
Ethnic Minority
28 (43%)
30 (42%)
58 (42%)
No. of Chronic Conditions
4.6
4.5
4.6
Annual Household income
<$10,000
33 (51%)
45 (64%)
78 (58%)
Female
Intervention Group
Intervention participants received:
• a mean of 6 in-person visits
• a mean of 3.5 follow-up phone contacts
Outcome Measures
• Response rate
– 50% reduction in depression scores
• Remission rate
– no longer meets DSM criteria
PEARLS Study Results
6 month (N=138)
JAMA 2004; 291:1569-1577
60
54
50
44
Percent
40
34
30
22
20
10
10
8
0
≥50% drop on HSCL-20
P<.01
% Achieving Remission
P<.01
Usual Care
Intervention
% Reporting Any
Hospitalizations
P=.07
PEARLS Study Results
• Quality of Life
– Improved Emotional Well-being
– Improved Functional Well-being
Antidepressant Usage
• 35% of all participants were on antidepressants at the
beginning of study.
• 7 (9.7%) intervention participants started an
antidepressant medication during the study period vs. 4
(6.1%) participants in the usual care group.
• 5 (6.7%) participants in each group stopped using an
antidepressant during study.
Cost Assessment
Mean costs of providing the PEARLS program per
participant:
•
•
•
•
•
•
$422 for PST intervention
$28 for follow-up phone calls
$12 in psychiatric follow-up phone calls
$87 for psychotherapy quality assurance
$81 for depression management team sessions
Total mean cost per participant = $630
Conclusions
Dissemination of the PEARLS program
within existing community social service
organizations has the potential to
significantly improve the well-being and
function of depressed older adults served
by these organizations.
From Fixsen DL, Naoom SF, Blasé KA, Friedman RM, Wallce F. Implementation Research: A Synthesis of the Literature.
Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation
Research Network (FMHI Publication #231), 2005. Available at URL: http://nirn.fmhi.usf.edu/resources/publications/Monograph/
PEARLS: Policy and
Management
Pamela Piering, Director
Aging and Disability Services
Seattle Human Services Dept
October 23, 2008
Learning Objectives
• The elements of the PEARLS intervention
in a community setting
• Understand the steps required to bring this
new program from research to practice
• Identify and explore opportunities to attract
funding from new partners
Moving From Research to
Practice
• Find funding to implement PEARLS
• AAA Advisory Council
– .5 FTE discretionary funding 2004, now 1.0 (Older
Americans Act)
• Adjust present psychiatrist role to provide
PEARLS consultation
• Advocate for State resources: new AAA pilot,
Spokane WA
Research to Practice,
Adaptations
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•
•
•
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Now serving age 50+ with new funding
Phone follow up calls completed in 3 months
Initiated food voucher/food card
Sessions may run from 4 – 6 in number
Initiated 30 day in-home visits when team
Supervisor determines client meets PEARLS
criteria
• Multiple referral sources instead of a primary
screener.
Educating Policymakers
• JAMA article, April 2004
• ADSA funded “PEARLS Toolkit” now
downloadable from UW web site
• Bring information, results to ADS Advisory
Council and Sponsors, Seattle, United Way
and King County
• Education of local funder: King County
Veterans and Human Services Levy
PEARLS Expansion
• CDC new research study with University of
Washington brings .5 FTE Implementation
Manager to study best referral flow
• King County Veterans and Human Services Levy
brings $220,000 in 2008, renewable six years.
Two new subcontractors:
– African American Elders Project
– IDIC Filipino elders “drop-in” center
• New ADS internal pilot: Chinese elders
– Three clients currently enrolled. Learning pros/cons of
using this approach work for this community
Challenges and
Opportunities
• Training now through new UW center: CHAMMP
– Recently offered: September 24-26 2008, Seattle
• Consider adding new mental health provider for
PEARLS through Medicaid funding
• Document results from expansion projects, seek to
extend funding statewide
• Link to overall health promotion work in the
community
Challenges and
Opportunities
• Identifying appropriate clients, and flow
• Referral process
• Encouraging Medicaid LTC clients with wellness
focus
• Use of incentives
• New easy-to-use data system needed, show
outcomes, fidelity to original
• PEARLS counselors have many expectations in
addition to client services: training, education,
“championing”, handling inquiries, etc
“Prior to participating in the PEARLS
program I lacked motivation, was severely
depressed, and suffering from chronic pain.
Having completed the program, I am happy
to say that I have successfully overcome
these difficulties, thanks to my counselor
and the tools and exercises he presented.”
PEARLS:
A Counselor’s Perspective
Susy Favaro, MSW
Social Worker, Northshore Senior Center
PEARLS Website
http://depts.washington.edu/pearlspr/
Questions & Answers
Future PRC-HAN Webinars
All 3:00-4:30 pm EST
More on Evidence-based Programs
Wed., October 29: Healthy IDEAS
Relevant to all Evidence-based
Programs
Thurs., November 13: Money Matters
To Register:
http://ncoa.org/content.cfm?sectionID=64