An Evaluation of Geriatric Home Healthcare Depression Assessment and Care Management: Are

ABSTRACT


Background
Integrated care models (ICM) providing BOTH psycho-social and physical health care management to older persons with multiple chronic conditions (MCC) receiving home health care (HHC) services, produce superior health outcomes (less disability, depression, healthcare use). However, traditional Medicare HHC services are focused on the provision of acute physical health outcomes, leading to an underdetection and under-treatment of depression among HHC elders. Responding to this gap in care, the Centers for Medicare and Medicaid Services (CMS) incorporated additional depression screening questions into the OASIS-C assessment (PHQ-2). However, CMS did not mandate HHC agencies to conduct any further depression evaluation or follow-up monitoring for patients who had depression. Thus, leaving depression screening, monitoring, and treatment initiatives to the voluntary action of HHC agencies, creating a pressing need to evaluate how changes were implemented and utilized. Thus, the first aim of this study evaluated the extent to which nurses delivered the new DCM required by CMS. Next, because CMS mandated attention to physical outcomes for eligibility and coverage, the second study aim evaluated depression detection and its impact on participants' mood and disability. Together, these factors underscore the importance and clinical meaningfulness of demonstrating how DCM impacts disability outcomes.

Methods
A retrospective chart review was conducted using clinical and administrative records (N=100) of new HHC admissions (eligibility: age 65,+ positive depression, disability, MCC). Descriptive analyses (characterize sample; DCM activities), multivariate, and regression analyses (association of DCM components /ADL improvement). Results: Nurses did not use evidence-based depression standards or DCM, and depression screening was conducted once at the assessment visit and without follow-up (discharge, recertification, transfer). Patients had depression diagnosis (60 %), positive depression screens (40%), and were prescribed antidepressants (65%). Having depression care plans and depression medication was significantly associated with large ADL improvements.

Discussion
The study population did not get appropriate mental health or social support during the HHC episode, despite improvements in depression screening. Most likely, this was due to several factors, including lack of protocols for nurse depression assessment and monitoring, inconsistent use of care plans, lack of training, nurses' discomfort addressing depression, stigma, and patients' health complexity.

Conclusions
Further changes are recommended to improve DCM within the current HHC system, including mandated depression assessment that may lead to treatment and ongoing management for patients who have positive depression screens. Provision of both disability and DCM has the potential to increase the effects of HHC treatments to lessen disability worsening, improve quality of life, and reduce costs. Limitations: Retrospective chart review is dependent on the accuracy of medical records. Depression measures were limited to depression screens but not followed up by a structured or semi-structured interview to validate the presence of depression.

Lessons
Medicare HHC agencies need to consider policy changes that incorporate evidence-based ICM interventions that redesign and improve care for elders with MCC. Further success can be attained by providing nurses depression education, training, and skills to ensure they have the competencies to provide ICM which incorporates disability and DCM, addressing the physical, mental and social healthcare.