This article described the HOME model for depression screening in home health care. The aim of the model is to deal with low rates of depression detection in medically ill homebound elderly. Accurate recognition by homecare workers is a critical first step toward improving depression care. HOME draws upon evidence-based research on depression in older adults. A key innovation is the use of a collaborative and interdisciplinary partnership among homecare nurses, social workers, mental health therapists, homecare supervisors, and primary-care physicians. The purpose of the partnership approach was to provide depression training and to integrate a depression screening protocol into routine homecare practice in order to improve detection of late-life depression in elderly homecare recipients. The overall management of depression in older homecare patients included a follow-up psychosocial interview, which allowed for clinical judgment, an evidence- based depression treatment in the patient’s home (Gellis et al., 2007
), and ongoing medication management with the primary-care physician.
During a period of 18 months, we investigated the concordance between homecare workers and research diagnostic raters on the prevalence of depression among medically ill homecare elderly. We found modest agreement between homecare workers’ reports and research ratings of depressive symptoms, whereby homecare workers were less likely to report depression in patients than research interviews. We found that patient medical comorbidity, functional disability, and less social contact were associated with the presence of clinically significant depressive symptoms by both sources (homecare and research ratings) when compared with depression-absent cases. The agency staff reported high satisfaction with the initial screening results, while attempting to reduce the number of patients who were inaccurately identified as depressed by the homecare workers. Agency managers learned that continuous reminders to staff about screening in biweekly team meetings as well as e-mails increased the frequency of depression screens as well as social work referrals for follow-up assessments. Ongoing advanced training in depression recognition and referral will likely improve assessment skills among homecare workers to minimize false positives.
Reports have described many barriers to accurate screening for depression among older homecare patients, including agency time constraints, deficient worker knowledge and lack of interest in training in mental health, scarcity of agency referral resources, patient stigma, and negative attitudes toward older persons among health care workers, to name a few (Bruce et al., 2007
; Gellis, 2009
). The heterogeneity of depression, coupled with physical and cognitive impairment, social vulnerabilities, and co-morbid medical conditions prevalent in homecare patients, also makes it more difficult for accurate assessment, diagnosis, and treatment in this elderly population (Blazer, 2003
Other impediments to developing depression-screening initiatives in homecare settings include agency financial constraints and service reimbursement. Homecare agencies generally focus on medical diagnoses and health issues that drive the treatment plan. Uncertainty in detecting and treating mental health problems, the number of reimbursable visits allowed, and time limitations during a home visit may lead to minimizing the level of psychological distress in older homecare patients, and thus attributing psychological symptoms to the medical illness. The stigma associated with mental illness may also influence the homecare professional and older patient’s communication about depression during the assessment. The homecare worker may hesitate in raising concerns about mental health issues since it may cause embarrassment for the older homecare patient and increase anxiety for the worker.
Targeted training in depression screening and allowing for clinical judgment and decision making in the presence or absence of gateway depression symptoms such as anhedonia and depressed mood may be indicated. For those patients who are depressed but show no signs of sadness, other training in assessment methods may be needed on subtypes of depressive disorders, including minor, subthreshold, subdysthymic, nondysphoric, and masked depression (Gallo, Rabins, & Anthony, 1999
This study provides further data on the clinical detection and prevalence of depression in elderly homecare patients. However, the study found misclassification of depression severity by homecare workers, which requires additional investigation. Reasons for such discrepancy may include the reluctance of medically ill homebound patients to communicate with their homecare worker about an emotional problem. A lack of homecare-professional training on depression may lead to hesitancy in workers using screening questions at all or using them improperly. There may be times during an assessment that neither the older patient nor the homecare worker may suspect that some somatic symptoms may be the result of an underlying depression rather than a medical illness.
The study used one homecare site; though not representative of all nonprofit or for-profit homecare agencies, it was statistically characteristic of home health care agencies nationally. Patients who were cognitively impaired (5%) and those who could not provide consent (< 2%) were excluded. The study did not collect demographic information on the homecare personnel. This type of information may assist researchers to focus educational efforts on depression screening. However, some researchers have found that regardless of years of experience or level of education, a majority of health care professionals reported that they did not assess their older patients for depression (Proffitt, Ausberger, & Byrne, 1996
Screening for the detection of depressive disorders involves the use of easily administered, inexpensive procedures to identify older adults who may be experiencing mental health problems. This is critical since depression is a treatable mental health condition. Criteria to justify mental health screening in an agency include the following:
- Is the incidence high enough to justify the cost of screening in an agency?
- Does the problem have a significant effect on the quality of life of the older adult?
- Is effective treatment available for late-life depression?
- Are available depression-screening instruments valid and cost-effective?
- Are the adverse effects (if any) of depression-screening tests acceptable to older adult clients?
It is clear from this study that the prevalence of depression among older adults is frequent enough and causes sufficiently serious negative outcomes to warrant screening. In the current homecare environment in which staff turnover, time, and cost factors often limit use of mental health specialists, homecare professionals are often called upon to attend to myriad elderly patient needs. Efforts to improve the identification of depression in elderly homecare patients may be targeted at cardinal symptoms (i.e., anhedonia and depressed mood) (Brown, Kaiser, & Gellis, 2007
). Educational plans would include teaching homecare professionals appropriate home-based depression-assessment strategies with their older patients. Homecare professionals can develop skills in identifying symptoms such as anhedonia and sadness, and understand how pain and hopelessness are exhibited in depressed patients with chronic medical disease.
Given that high rates of depression are prevalent in medically ill elderly, home care is an ideal setting to intervene for late life depression. Home care serves a large elderly population that is particularly vulnerable to depression because of their co-morbid medical conditions and homebound status. As part of the community-based health care system, home care is amenable and ready for practice modification to address the gap in depression care. Home care employs professionals that can treat depressed elderly with appropriate evidence-based training. Home care can take advantage of internal social work staff working synergistically with medical nurses and externally with primary care in providing depression care management to create a tightly integrated and effective treatment model for depressed medically ill older adults.
Home health care services have grown rapidly during the past 2 decades and have become a vital source of community-based care for a majority of medically ill elderly patients. Depression is prevalent in this isolated, frail, and vulnerable population as compared with the general community-dwelling elderly population. Frequently, depression treatment is not part of routine care in homecare agencies, often leading to deterioration in physical functioning, exacerbation of chronic medical conditions, and increased risk for suicide in elderly patients. Depression continues to go undetected and undertreated in homecare agencies. Integration of depression-screening protocols into homecare agencies is vital to assist homecare clinicians in timely evaluation of their older patient’s depression status and overall improvement of their psychosocial care. Collaboration among homecare staff, managers, and internal mental health therapists can lead to innovative depression-screening and treatment initiatives for improvement of depression care among medically ill homebound elderly. Home health care can play a critical role in identifying depressed older adults in the community and providing referrals for evidence-based depression care.