Clinical effectiveness of integrating depression care management into medicare home health: the Depression CAREPATH Randomized trial.
OBJECTIVE
Among older home health care patients, depression is highly prevalent, is often inadequately treated, and contributes to hospitalization and other poor outcomes. Feasible and effective interventions are needed to reduce this burden of depression.


OBJECTIVE
To determine whether, among older Medicare Home Health recipients who screen positive for depression, patients of nurses receiving randomization to an intervention have greater improvement in depressive symptoms during 1 year than patients receiving enhanced usual care.


METHODS
This cluster randomized effectiveness trial conducted at 6 home health care agencies nationwide assigned nurse teams to an intervention (12 teams) or to enhanced usual care (9 teams). Between January 13, 2009, and December 6, 2012, Medicare Home Health patients 65 years and older who screened positive for depression on routine nursing assessments were recruited, underwent assessment, and were followed up at 3, 6, and 12 months by research staff blinded to intervention status. Patients were interviewed at home and by telephone. Of 502 eligible patients, 306 enrolled in the study.


METHODS
The Depression Care for Patients at Home (Depression CAREPATH) trial requires nurses to manage depression at routine home visits by weekly symptom assessment, medication management, care coordination, education, and goal setting. Nurses' training totaled 7 hours (4 onsite and 3 via the web). Researchers telephoned intervention team supervisors every other week.


METHODS
Depression severity, assessed by the 24-item Hamilton Scale for Depression (HAM-D).


RESULTS
The 306 participants were predominantly female (69.6%), were racially/ethnically diverse (18.0% black and 16.0% Hispanic), and had a mean (SD) age of 76.5 (8.0) years. In the full sample, the intervention had no effect (P = .13 for intervention × time interaction). Adjusted HAM-D scores (Depression CAREPATH vs control) did not differ at 3 months (10.5 vs 11.4, P = .26) or at 6 months (9.3 vs 10.5, P = .12) but reached significance at 12 months (8.7 vs 10.6, P = .05). In the subsample with mild depression (HAM-D score, <10), the intervention had no effect (P = .90), and HAM-D scores did not differ at any follow-up points. Among 208 participants with a HAM-D score of 10 or higher, the Depression CAREPATH demonstrated effectiveness (P = .02), with lower HAM-D scores at 3 months (14.1 vs 16.1, P = .04), at 6 months (12.0 vs 14.7, P = .02), and at 12 months (11.8 vs 15.7, P = .005).


CONCLUSIONS
Home health care nurses can effectively integrate depression care management into routine practice. However, the clinical benefit seems to be limited to patients with moderate to severe depression.


BACKGROUND
clinicaltrials.gov Identifier: NCT01979302.
Department of Psychiatry, Weill Cornell Medical College, White Plains, New York.
Martha L
ML
Bruce
Department of Psychiatry, Weill Cornell Medical College, White Plains, New York.
Patrick J
PJ
Raue
Department of Psychiatry, Weill Cornell Medical College, White Plains, New York.
Catherine F
CF
Reilly
Department of Psychiatry, Weill Cornell Medical College, White Plains, New York.
Rebecca L
RL
Greenberg
Department of Psychiatry, Weill Cornell Medical College, White Plains, New York2New York Presbyterian Hospital-Westchester Division, White Plains.
Barnett S
BS
Meyers
Department of Psychiatry, Weill Cornell Medical College, White Plains, New York3Department of Health Policy and Research, Weill Cornell Medical College, New York, New York.
Samprit
S
Banerjee
Department of Psychiatry, Weill Cornell Medical College, White Plains, New York2New York Presbyterian Hospital-Westchester Division, White Plains4Montefiore Home Health Agency, Bronx, New York.
Yolonda R
YR
Pickett
Department of Psychiatry, Weill Cornell Medical College, White Plains, New York5Rhode Island Hospital, Providence6Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, Rhode Island.
Thomas F
TF
Sheeran
Department of Psychiatry, Weill Cornell Medical College, White Plains, New York7Brookdale Center for Healthy Aging, Hunter College, New York, New York.
Angela
A
Ghesquiere
Triumph Home Health Care, Livonia, Michigan.
Diane M
DM
Zukowski
United HomeCare, Miami, Florida.
Vianca H
VH
Rosas
Visiting Nurse and Hospice for Vermont and New Hampshire, West Lebanon, New Hampshire.
Jeanne
J
McLaughlin
Baptist Home Health Network, Little Rock, Arkansas.
Lori
L
Pledger
Penn Care at Home, Bala Cynwyd, Pennsylvania.
Joan
J
Doyle
Montefiore Home Health Agency, Bronx, New York.
Pamela
P
Joachim
Department of Psychiatry, Weill Cornell Medical College, White Plains, New York.
Andrew C
AC
Leon
D000368:Aged; D000369:Aged, 80 and over; D003866:Depressive Disorder / Q000523:psychology / Q000628:therapy*; D005260:Female; D006699:Home Care Services; D006801:Humans; D008297:Male; D006278:Medicare; D010348:Patient Care Team; D016896:Treatment Outcome; D014481:United States