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Psychiatr Serv. Author manuscript; available in PMC 2016 December 01. Published in final edited form as: Psychiatr Serv. 2015 December 1; 66(12): 1365–1368. doi:10.1176/appi.ps.201400481.

Practices of depression care in home health care: Home health clinician perspectives Yuhua Bao, Weill Cornell Medical College - Healthcare Policy and Research

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Ashley A. Eggman, Weill Cornell Medical College - Healthcare Policy and Research, New York Joshua E. Richardson, Weill Cornell Medical College - Healthcare Policy and Research, New York Thomas Sheeran, and Rhode Island Hospital and Warren Alpert Medical School of Brown University - Psychiatry and Human Behavior, Providence, Rhode Island Martha L. Bruce Weill Cornell Medical College - Department of Psychiatry, White Plains, New York Yuhua Bao: [email protected]

Abstract Author Manuscript

Objective—To assess any gaps between published best practices and real-world practices of treating depression in home health care (HHC), and barriers to closing any gaps. Methods—A qualitative study based on semi-structured interviews with HHC nurses and administrators from five home health agencies in five states (n=20). Audio-recorded interviews were transcribed and analyzed by a multi-disciplinary team using grounded theory method to identify themes. Results—Routine home health nursing care overlapped with all functional areas of depression care. However, there were reported gaps between best practices and real-world practices. Gaps were associated with perceived scope of practice by HHC nurses, knowledge gaps and low selfefficacy in depression treatment, stigma attached to depression, poor quality of antidepressant management in primary care, and poor communication between HHC and primary care.

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Conclusions—Strategies to close gaps between typical and best practices need to enhance HHC clinician knowledge and self-efficacy with depression treatment and improve the quality of antidepressant management and communication with primary care. Keywords depression; home health care; depression care management; communication

Disclosures The authors report no competing interests.

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Major and minor depression meeting clinical diagnostic criteria affects almost 1 in 4 older home health patients (1) and is associated with an increased risk of falls, (2) hospitalization, (3) and excess service use. (4) Home health care (HHC) nurses are well positioned to play an active role in addressing depression. They make an average of 17 visits to each home health patient (5) and can potentially conduct treatment follow-up as well as initial needs assessment. They commonly manage multiple chronic conditions (6) and strongly endorse a holistic approach to patient care.

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Despite the unique opportunity, depression may be seriously under-recognized and poorly managed in HHC. Studies have shown that the average home health nurse had difficulties accurately assessing depression. (7) Use of antidepressants was characterized by mismatches between needs and treatments and sub-optimal dosages among users. (1) Physician-nurse communication and collaboration, essential for all domains of HHC but especially important for depression care, is poor. (8) Quality improvement of depression care in HHC needs to be informed by a fuller understanding of gaps between typical practices and known best practices of depression care in this setting, and barriers to closing the gaps. In this study, we aimed to assess the gaps and barriers at the levels of home health clinicians and physicians. We based our assessment on interviews with home health nurses and administrators participating in a research study testing a depression care intervention in HHC. Given our purposes, we focused on study participants’ observations regarding routine practice of depression care prior to their participation in the quality improvement intervention.

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We sought to recruit administrators and nurses from five home health agencies located in 5 states in the Northeast, South, and Midwest of the U.S between February and November 2012. These 5 agencies had recently participated in a nursing team-randomized trial of the Depression CAREPATH (Care for Patients At Home) intervention for older home health patients. (9, 10) We determined three types of key informants who would provide complementary perspectives on study topics: home health nurses who worked on a CAREPATH intervention team and home health nurses who worked on a usual care team, nurse supervisors of CAREPATH intervention teams, and medical or clinical directors who played a leadership role in facilitating their agency’s participation in CAREPATH.

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We worked with a liaison at each agency to identify potential informants, whom the research team then contacted by email or phone to recruit for the study and schedule phone interviews. No potential informants we approached refused to participate. Each informant provided signed written consent and received a $75 gift card for participating in the study. This study received approval from the Institutional Review Board at Weill Cornell Medical College. The research team developed semi-structured interview guides tailored for different types of informants (Online Supplement 1), which covered several domains including typical practices of depression care prior to CAREPATH. The interview guides were pilot-tested

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with a nurse, a nursing supervisor and a director from agencies that did not participate in CAREPATH and iteratively revised throughout the interviews. The first author conducted one-on-one telephone interviews with all informants. Audiorecorded interviews were transcribed by a third-party service and analyzed using grounded theory method, (11) an established qualitative analytic approach by which researchers generate overall themes by iteratively reading and reviewing interview text, attributing labels (“codes”) to salient text, and documenting recurring themes that “emerge” from those transcripts.

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Two investigators independently coded each transcript and met to discuss the definitions of codes and negotiate consensus around coding. To enhance analytical rigor, a third investigator independently coded selected transcripts and participated in coding meetings to provide outside voice and help negotiate consensus. The process was documented throughout and led to the development of a codebook and themes. Data were organized and managed using the qualitative analysis software, Nvivo 9 (QSRInternational 2010) to facilitate text and code consolidation and, in turn, theme development.

RESULTS We conducted interviews with 6 directors, 5 supervisors, and 9 nurses. All but one informant were females. Average years of experience in HHC were 16 for directors, 9 for supervisors and 10 for nurses. Average length of the interviews was 45 minutes (ranging from 33 to 56 minutes).

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We summarize in Online Supplement 2 currently known best practices of depression care grouped by five clinical functions: screening, assessment, case coordination, antidepressant management, and patient education and goal setting. (9) Participants reported that all five clinical functions overlapped with routine home health nursing care. However, based on their description of typical practices prior to participating in CAREPATH, gaps of varying extents existed between typical and best practices in each of these functional areas, which we detail below but also summarize in Online Supplement 2.

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The best-practice protocol recommends initial screening using Patient Health Questionnaire (PHQ)-2, a two-question depression screening tool included in the mandated, start-of-care (SOC) patient assessment for all Medicare home health patients. Several agency directors and supervisors believed that the addition of PHQ-2 greatly enhanced clinician awareness of depression. However, some informants suggested that the typical approach undertaken by nurses may have been inadequate or ineffective in detecting depression. Often, nurses would reportedly “go right in and just read off the answers” rather than conduct a clinically informed interview. Although there was a perception among nurses that it might take several weeks/visits before patients would feel comfortable talking about depression and that the SOC visit was usually too involved to do a good screening, none of the 5 agencies had a clinical management system that prompted nurses to reassess PHQ-2 at follow-up visits.

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For patients who screen positive on the PHQ-2 (i.e. a score of 3 or higher), the best-practice recommends further assessment of depression severity using, for example, the PHQ-9. However, such practice was adopted by only 1 of the 5 agencies before CAREPATH. For patients with clinically significant depression (i.e., PHQ-9 > 10) the best-practice recommends that home health clinicians follow the course of patients’ symptoms each week/ visit using the PHQ-9 to support case coordination, antidepressant management, and patient education. However, prior to CAREPATH, none of the 5 agencies practiced weekly followup assessment using PHQ-9.

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Consistent with the best practice protocol, home health nurses in our study routinely reported to physicians about patients’ depression as they would for other conditions. However, they also reported issues around nurse-physician communication. A handful of nurse informants expressed frustration regarding not being able to communicate with patients’ physicians in a timely manner and indicated that they mostly spoke with the nurses and receptionists at the physician’s office and rarely with the physician in-person. This seems to be a general issue that does not pertain specifically to depression. Primary care physicians (PCPs), with whom nurses most often communicated, were reportedly receptive of home health nurses’ reports, but often wanted to evaluate the patient themselves before making a clinical decision (e.g., ordering a new antidepressant). Accordingly, nurses perceived their roles as raising the issues to the awareness of the PCPs and facilitating the PCPs’ independent evaluation by, for example, scheduling an office visit for the patient, which is consistent with the best practice protocol. However, our results suggest that visits to PCPs alone did not guarantee adequate attention to depression since, according to our informants, older patients might be “afraid or not sure how to ask the doctor or tell the doctor [about their depression]” during a visit. Several informants believed that home health nurses had a role to play in educating and coaching patients to make the most out of their visits. Nurse informants from all five agencies reported that, prior to CAREPATH, a general practice was to refer depressed patients to social workers at their agencies. Nurses believed that social workers were better trained and more effective at addressing psychosocial issues of patients. Nurses also perceived that referral to social workers lessened burdens for clinicians “going in and dealing with the medical piece.”

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Meanwhile, there seemed limited care coordination between nurses and social workers once patients were referred. Several nurses mentioned that they would read the clinical notes by social workers on shared patients, but routine integration of social workers into the weekly nursing team case conference – an important mechanism for case management and coordination in HHC – was rare. In general, nurse informants expressed little knowledge of the types of interventions social workers conducted with depressed patients. In addition, a general perception shared by informants from 4 of the 5 agencies was that their agencies had too few social workers to meet the plethora of psychosocial needs of patients. Home health nurses in our study reported that they would conduct patient education and medication reconciliation (by comparing the list of medications currently taken by patients with the list of physician orders) for antidepressants as they would for other medications.

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Although nurses reported that many patients they cared for had significant depressive symptoms despite taking antidepressants, prior to CAREPATH, nurses largely did not consider antidepressant management – the process of finding an effective regimen for individual patients – within their purview. Several nurse informants believed that “it’s up to the doctor to change it [antidepressant] if it is required.” Educating patients about depression and its treatment and assisting patients with setting personal goals is highly consistent with routine HHC and strongly endorsed by our informants. Our informants also perceived a role to connect patients with community resources (e.g., senior centers) as a way to increase social interactions and pleasurable activities for depressed patients.

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Below we report results regarding barriers to addressing gaps in depression care that pertain to clinicians (both HHC and non-HHC). Online Supplement 2 summarizes how these barriers map with quality gaps in each clinical functional area of depression care. Our results revealed that prior to CAREPATH, home health nurses typically did not consider depression care within their scope of practice and preferred to have another provider such as a social worker or the PCP take full responsibility. Almost all supervisors and agency directors we interviewed believed that HHC as a profession attached greater importance and urgency to medical conditions than to depression or other mental health conditions. Nurses saw themselves as task-oriented and their roles as primarily delivering skilled nursing care.

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Lack of knowledge and training among nurses to adequately recognize and treat depression may have led to low self-efficacy in addressing depression. Several agency directors and supervisors believed that, prior to CAREPATH, their nurses commonly held misconceptions about depression and depression treatment, for example, that depression was a normal part of aging and that if a patient was taking antidepressants, no further management by HHC clinicians was needed. When reflecting on their own practices prior to CAREPATH, several nurses expressed a feeling of insufficiency about intervening once they identified depression: since they would not know what to do with it, they naturally avoided opening up the issue in the first place.

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Several informants also acknowledged a sense of uneasiness on their own part when assessing depression and engaging patients in depression care, suggesting stigma. For example, a nurse described her experience as follows, “I just felt uncomfortable asking too many questions. I tried to stay positive as I could and so I didn’t go there.” An agency director believed that some nurses felt that “if they put it [depression] on the patient’s record, they’ve kind of given them [a] scarlet letter.” Our informants observed an overall low level of antidepressant management undertaken by patients’ PCPs, who accounted for an overwhelming proportion of prescribing physicians in this population. Reportedly, PCPs tended to “never increase the dose” or change medications for patients not responding to their antidepressant medication.

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DISCUSSION Using qualitative reports of HHC clinicians and administrators, this study found that, although the clinical functions of depression care fit within routine HHC practice, gaps of varying extents existed between typical and best practices of depression care in all functional areas. These gaps were associated with home health nurse beliefs about their scope of practice, lack of knowledge, low self-efficacy, and stigma attached to depression and depression care, ineffective inter-clinician (especially nurse-PCP) communication and collaboration, and poor antidepressant management in primary care.

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Our findings elucidated important factors pertaining to home health clinicians and physicians that contributed to the gaps in depression care, thereby shedding light on potential strategies to close the gaps. A prominent finding was that, prior to receiving depression care intervention, limited knowledge and self-efficacy in treating depression by home health nurses underlay the low priority nurses assigned to depression and, in turn, partly explained their passivity or inaction towards depression and tendency to delegate depression care to other providers. This finding calls for interventions that boost nurse selfefficacy and provide practical tools to enable nurses to play an active role in caring for depression that concords with best-practice guidelines.

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Our findings highlight PCPs as an important link in depression care quality improvement for home health patients. Almost a third of elderly Medicare fee-for-service patients receiving HHC are taking antidepressants (12) and PCPs are responsible for the vast majority of antidepressant prescriptions in this population. (13) Given that medication-related decisions ultimately rest with the physician and not the home health nurse, lack of knowledge and self-efficacy by PCPs with antidepressant management (14) constitutes a major barrier. Adding to the concern are challenges in timely and effective communication between home health nurses and PCPs: depression care management may be especially susceptible to communication breakdowns because of the gaps in training and practice and lower priorities assigned to depression care on both sides. Future interventions should seek to engage clinicians at the PCP’s office in addition to addressing communication skills and effectiveness of home health nurses.

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Although we focused on barriers pertaining to clinicians in this paper, addressing these barriers alone may not be sufficient to close the quality gaps in depression care. Our interviews revealed factors at the system and home health agency levels that provide misaligned incentives for depression quality improvement in HHC. (15) While recent reforms such as Accountable Care Organizations hold promises to align incentives, explicit policy tools are needed to achieve accountability for mental health outcomes. Our study has limitations. By design, the qualitative data we collected reflected the (highly pertinent) perspectives of home health nurses and administrators in our study and not perspectives of other stakeholders such as home health patients. The five home health agencies in our study may have perceived a greater need to improve the quality of depression care than the average agency, indicated by their voluntary participation in a depression study. Finally, this research, like qualitative research in general, is not intended

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to be generalizable. However, readers may consider the findings “transferrable” to other circumstantial or organizational contexts.

CONCLUSION Based on qualitative reports by home health nurses and administrators, gaps between typical and best practices existed in each clinical area of depression care in HHC. Strategies to close the gaps need to enhance HHC clinician knowledge and self-efficacy with depression care, address the low level of antidepressant management by primary care physicians, and improve the quality of home health nurse-physician communication.

Supplementary Material Refer to Web version on PubMed Central for supplementary material.

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Acknowledgments This research is funded by the National Institute of Mental Health (K01MH090087, R01 MH082425). The authors thank Catherine Reilly, M.P.H., for assistance with recruitment of informants.

References

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Practices of Depression Care in Home Health Care: Home Health Clinician Perspectives.

The study assessed gaps between published best practices and real-world practices of treating depression in home health care (HHC) and barriers to clo...
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