Project ADAPT Assessing Depression and Proactive Treatment

1. Project ADAPTAssessing Depression and Proactive Treatment The Minnesota Area Geriatric Education Center (MAGEC) ADAPT serving geriatric populations in rural communities.

2. Why Geriatric Depression? • NIMH estimates one-in-six older adults suffer from depression. • Fewer than 10% receive a diagnosis & appropriate treatment. • Based on these estimates, more than 89,000 older Minnesotans struggle with depression. • Financial burden of depression exceeds $43.7 billion annually. ADAPT serving geriatric populations in rural communities.

3. Project ADAPT Clinic Model • SCREEN (all patients >65) • ASSESS (all patients with positive screen) • COUNSEL (patients with depression) • TREAT (willing patients) • FOLLOW (provide ongoing support) • IMPROVE (quality of life improves) ADAPT serving geriatric populations in rural communities.

4. Design ADAPT Materials • Review/Revise Project IMPACT materials to reflect realities of rural Minnesota • Audience Identification • Design ADAPT training materials • Develop inter-professional ADAPT team ADAPT serving geriatric populations in rural communities.

5. Identify ADAPT Clinical Sites • Select three regions with significant rural populations in Minnesota • Request RGEC staff identify primary care clinics within their regions • Invite clinic sites within the selected regions to send clinic staff (ANPs, RNs, MSWs, CNAs) to regional ADAPT training sessions. ADAPT serving geriatric populations in rural communities.

6. Provide ADAPT Training • Trainings held in selected regions • Participants came from multiple clinical sites, and unexpectedly included staff from hospitals, nursing facilities, county public health agencies, and parish nurses. • Half day training session provided by inter-disciplinary team about geriatric depression and Project ADAPT ADAPT serving geriatric populations in rural communities.

7. Project ADAPT ParticipationRequirements • Designate a nurse and a social worker, psychologist, or medical assistant be trained as Depression Care Specialists during a four-hour training session to be held in your region of the state • Apply the Geriatric Depression Team model of care in your clinic for a six-month period (June-December 2004) • Submit pre and post test evaluation data on the effectiveness of this model in your clinic setting ADAPT serving geriatric populations in rural communities.

8. DepressionCare Specialist • The Depression Care Specialists (DCS) are trained to be knowledgeable of all aspects of geriatric depression. They support the primary provider through: - patient education and monitoring of medications, - identifying and managing treatment plan (After the treatment plan is identified by the physician and the patient) - Arranging treatment referrals when appropriate. ADAPT serving geriatric populations in rural communities.

9. Project ADAPT Model • Physician • Assess • Diagnose • Develop Treatment Plan • Inform Depression Care Specialist • Depression Care Specialist • Administer GDS • Provide Patient Education • Conduct Patient Follow-Up Interviews • Communicate Results to Physician ADAPT serving geriatric populations in rural communities.

10. Project ADAPT Clinic Tools • Geriatric Depression Scale • Depression Assessment Tool • Depression Treatment Protocol • Start Feeling Better (Patient Education Booklet) • PowerPoint Depression Education • Treatment Options Materials ADAPT serving geriatric populations in rural communities.

11. Evaluation of Project ADAPT • Written surveys at 6 months requested information about the use of ADAPT materials, and number of patients evaluated for depression and those with a positive screen who accepted treatment (n=15 of 44 clinical sites) • Telephone follow up of written surveys at 10 months requested information about barriers to ADAPT implementation ADAPT serving geriatric populations in rural communities.

12. Project ADAPT Process Outcomes • Training attendees were from multiple locations beyond primary care clinics • Multiple disciplines represented, including: RNs, LPNs, Social Workers, Discharge Planners, Senior Service Coordinators, Psychologists, Physician Assistants • Rural clinics too small to designate one person as a DCS ADAPT serving geriatric populations in rural communities.

13. Project ADAPT Outcomes • 10/15 sites used some ADAPT components; no site reported using all the components • 5 sites not using any ADAPT materials included 4 primary care clinics and 1 hospital • 135 patients screened using the GDS • 53 screened positive for depression • 45 treated for depression; 8 refused treatment • Patient Education Booklet was the most often used component No sites used the assessment algorithm, treatment and monitoring protocol forms, documentation and CPT coding guidelines • No agency requested consultation from the ADAPT team or referred patients to the telephone group therapy • Those sites using the GDS reported that the nurses and social workers who provided the assessments did not identify themselves as a geriatric depression specialist nor did they complete the other treatment or counseling responsibilities of the geriatric depression specialist ADAPT serving geriatric populations in rural communities.

14. Reasons ADAPT has faltered • Sites have not adopted a multidisciplinary approach to geriatric depression. • Providers don’t have time to address a positive screen at original patient visit • Patients with positive screens have refused treatment. (Reasons?) • The ADAPT tools are not ideal in non-clinic settings • A shorter screening tool would make screening more likely (The 15 item GDS is “too long”) ADAPT serving geriatric populations in rural communities.

15. Positive ADAPT Outcomes • More geriatric patients being screened for depression • Staff within clinics, facilities and agencies are more educated and aware of geriatric depression. • The ADAPT educational materials are being used to train new staff and educate patients about depression. ADAPT serving geriatric populations in rural communities.

16. Clinical Implications • Rural needs • Prevalence • Inadequacy of available tools/processes • Education • Team Definition • Member roles • Responsibilities • Limitations on treatment options ADAPT serving geriatric populations in rural communities.

17. Research Implications • Smaller rural geographic region would improve recruitment and training efficiencies • More on-going support and training of clinical staff could improve data collection • Additional money (grant, insurance) to modify existing mental health services important • Need a team to do a research project • Established vs new partnerships between clinical staff and research team would strengthen research process ADAPT serving geriatric populations in rural communities.

18. The Project ADAPT Training Team • Teresa McCarthy MD, MS, Geriatrician • Merrie J. Kaas, DNSc, APRN, GeroPsych • Margaret Artz, PhD, Pharmacist • Marilyn Luptak, PhD, Clinical Social Worker • Anne Kane, MPH, Administrator ADAPT serving geriatric populations in rural communities.