James Gilmore

Community-Partnered Cluster-Randomized Comparative Effectiveness Trial of Community Engagement and Planning or Resources for Services to Address Depression Disparities

ABSTRACTBACKGROUNDDepression contributes to disability and there are ethnic/racial disparities in access and outcomes of care. Quality improvement (QI) programs for depression in primary care improve outcomes relative to usual care, but health, social and other community-based service sectors also support clients in under-resourced communities. Little is known about effects on client outcomes of strategies to implement depression QI across diverse sectors.OBJECTIVETo compare the effectiveness of Community Engagement and Planning (CEP) and Resources for Services (RS) to implement depression QI on clients’ mental health-related quality of life (HRQL) and services use.DESIGNMatched programs from health, social and other service sectors were randomized to community engagement and planning (promoting inter-agency collaboration) or resources for services (individual program technical assistance plus outreach) to implement depression QI toolkits in Hollywood-Metro and South Los Angeles.PARTICIPANTSFrom 93 randomized programs, 4,440 clients were screened and of 1,322 depressed by the 8-item Patient Health Questionnaire (PHQ-8) and providing contact information, 1,246 enrolled and 1,018 in 90 programs completed baseline or 6-month follow-up.MEASURESSelf-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use.RESULTSCEP was more effective than RS at improving mental HRQL, increasing physical activity and reducing homelessness risk factors, rate of behavioral health hospitalization and medication visits among specialty care users (i.e. psychiatrists, mental health providers) while increasing depression visits among users of primary care/public health for depression and users of faith-based and park programs (each pu2009<u20090.05). Employment, use of antidepressants, and total contacts were not significantly affected (each pu2009>u20090.05).CONCLUSIONCommunity engagement to build a collaborative approach to implementing depression QI across diverse programs was more effective than resources for services for individual programs in improving mental HRQL, physical activity and homelessness risk factors, and shifted utilization away from hospitalizations and specialty medication visits toward primary care and other sectors, offering an expanded health-home model to address multiple disparities for depressed safety-net clients.

Community-partnered Evaluation of Depression Services for Clients of Community-Based Agencies in Under-Resourced Communities in Los Angeles

ABSTRACTBACKGROUNDAs medical homes are developing under health reform, little is known regarding depression services need and use by diverse safety-net populations in under-resourced communities. For chronic conditions like depression, primary care services may face new opportunities to partner with diverse community service providers, such as those in social service and substance abuse centers, to support a collaborative care model of treating depression.OBJECTIVETo understand the distribution of need and current burden of services for depression in under-resourced, diverse communities in Los Angeles.DESIGNBaseline phase of a participatory trial to improve depression services with data from client screening and follow-up surveys.PARTICIPANTSOf 4,440 clients screened from 93 programs (primary care, mental health, substance abuse, homeless, social and other community services) in 50 agencies, 1,322 were depressed according to an eight-item Patient Health Questionnaire (PHQ-8) and gave contact information; 1,246 enrolled and 981 completed surveys. Ninety-three programs, including 17 primary care/public health, 18 mental health, 20 substance abuse, ten homeless services, and 28 social/other community services, participated.MAIN MEASURESComparisons by setting in 6-month retrospective recall of depression services use.KEY RESULTSDepression prevalence ranged from 51.9xa0% in mental health to 17.2xa0% in social-community programs. Depressed clients used two settings on average to receive depression services; 82xa0% used any setting. More clients preferred counseling over medication for depression treatment.CONCLUSIONSNeed for depression care was high, and a broad range of agencies provide depression care. Although most participants had contact with primary care, most depression services occurred outside of primary care settings, emphasizing the need to coordinate and support the quality of community-based services across diverse community settings.

Participation in Training for Depression Care Quality Improvement: A Randomized Trial of Community Engagement or Technical Support

Depressive disorders are leading causes of disability in the United States with racial disparities in access to, quality and outcomes of care in under-resourced communities.1-7 Primary care, depression quality improvement programs using team-based, chronic disease management can improve quality and care outcomes for depressed adults, including racial and ethnic minorities.8-17 Under healthcare reform, Medicaid behavioral health homes incentivize partnerships among healthcare, mental health, and social-community agencies (e.g. parks, senior centers), by noting “ Services must include prevention and health promotion, healthcare, mental health and substance use, and long-term care services, as well as linkages to community supports and resources.”18 However, few guidelines exist to organize diverse agencies into systems supporting chronic disease management. Also, no studies exist comparing the effects of alternative training approaches for depression quality improvement with diverse providers from healthcare and social-community programs. n nThis study analyzes data from Community Partners in Care (CPIC), a group-level, randomized, comparative-effectiveness study of two implementation approaches for evidence-based, depression quality improvement toolkits adapted for diverse healthcare and social-community settings. One implementation approach relies on more traditional technical assistance to individual programs (Resources for Services, RS). The other (Community Engagement and Planning, CEP) used community-partnered, participatory research (CPPR) principles to support collaborative planning across programs to implement the same depression care toolkits through a network.19-25 Programs randomized to each approach included healthcare and social-community programs.20-21 Six-month follow-up revealed that relative to RS, CEP improved depressed clients’ mental health-related quality of life, increased physical activity, and reduced homelessness risk factors; while reducing behavioral health hospitalizations and specialty medication visits, and increasing depression services use in primary care/public health, faith-based and park/community center programs with continued effects on mental health-related quality of life at 12-months.20,25 This study focuses on CPICs main intervention effects for primary program (i.e. program training participation) and staff-level (i.e. total training hours) outcomes, participation in evidence-based, depression quality improvement trainings. We hypothesized that CEP would lead to a broader range of staff training options than RS. To determine what types of organizations would participate in trainings, we compared interventions’ effects by program type (i.e. healthcare versus social-community). Based on prior work, we hypothesized that CEP relative to RS would increase mean hours of training participation, especially for social-community programs where such training is novel.26-28 To inform future depression quality improvement dissemination efforts in safety-net communities, we conducted exploratory analyses of interventions’ effects on staff training participation for each depression quality improvement component and by services sector.OBJECTIVEnCommunity engagement and planning (CEP) could improve dissemination of depression care quality improvement in underresourced communities, but whether its effects on provider training participation differ from those of standard technical assistance, or resources for services (RS), is unknown. This study compared program- and staff-level participation in depression care quality improvement training among programs enrolled in CEP, which trained networks of health care and social-community agencies jointly, and RS, which provided technical support to individual programs.nnnMETHODSnMatched programs from health care and social-community service sectors in two communities were randomly assigned to RS or CEP. Data were from 1,622 eligible staff members from 95 enrolled programs. Primary outcomes were any staff trained (for programs) and total hours of training (for staff). Secondary staff-level outcomes were hours of training in specific depression collaborative care components.nnnRESULTSnCEP programs were more likely than RS programs to participate in any training (p=.006). Within health care sectors, CEP programs were more likely than RS programs to participate in training (p=.016), but within social-community sectors, there was no difference in training by intervention. Among staff who participated in training, mean training hours were greater among CEP programs versus RS programs for any type of training (p<.001) and for training related to each component of depression care (p<.001) except medication management.nnnCONCLUSIONSnCEP may be an effective strategy to promote staff participation in depression care improvement efforts in underresourced communities.

Comorbid Depression and Substance Abuse Among Safety-Net Clients in Los Angeles: A Community Participatory Study

OBJECTIVEnDepression and substance abuse are common among low-income adults from racial-ethnic minority groups who receive services in safety-net settings, although little is known about how clients differ by service setting. This study examined characteristics and service use among depressed, low-income persons from minority groups in underresourced communities who did and did not have a substance abuse history.nnnMETHODSnThe study used cross-sectional baseline client data (N=957) from Community Partners in Care, an initiative to improve depression services in Los Angeles County. Clients with probable depression (eight-item Patient Health Questionnaire) from substance abuse programs were compared with depressed clients with and without a history of substance abuse from primary care, mental health, and social and community programs. Sociodemographic, health status, and services utilization variables were examined.nnnRESULTSnOf the 957 depressed clients, 217 (23%) were from substance abuse programs; 269 (28%) clients from other sectors had a substance abuse history, and 471 (49%) did not. Most clients from substance abuse programs or with a substance abuse history were unemployed and impoverished, lacked health insurance, and had high rates of arrests and homelessness. They were also more likely than clients without a substance abuse history to have depression or anxiety disorders, psychosis, and mania and to use emergency rooms.nnnCONCLUSIONSnClients with depression and a substance abuse history had significant psychosocial stressors and high rates of service use, which suggests that communitywide approaches may be needed to address both depression and substance abuse in this safety-net population.

Comparative Effectiveness of Two Models of Depression Services Quality Improvement in Health and Community Sectors

OBJECTIVEnThe effectiveness of community coalition building and program technical assistance was compared in implementation of collaborative care for depression among health care and community sector clients.nnnMETHODSnIn under-resourced communities, within 93 programs randomly assigned to coalition building (Community Engagement and Planning) or program technical assistance (Resources for Services) models, 1,018 clients completed surveys at baseline and at six, 12, or 36 months. Regression analysis was used to estimate intervention effects and intervention-by-sector interaction effects on depression, mental health-related quality of life, and community-prioritized outcomes and on services use.nnnRESULTSnFor outcomes, there were few significant intervention-by-sector interactions, and stratified findings suggested benefits of coalition building in both sectors. For services use, at 36 months, increases were found for coalition building in primary care visits, self-help visits, and appropriate treatment for community clients and in community-based services use for health care clients.nnnCONCLUSIONSnRelative to program technical assistance, community coalition building benefited clients across sectors and shifted long-term utilization across sectors.

Community Partners in Care: 6-Month Outcomes of Two Quality Improvement Depression Care Interventions in Male Participants

OBJECTIVEnLimited data exist on approaches to improve depression services for men in under-resourced communities. This article explores this issue using a sub-analysis of male participants in Community Partners in Care (CPIC).nnnDESIGNnCommunity partnered, cluster, randomized trial.nnnSETTINGnHollywood-Metropolitan and South Los Angeles, California.nnnPARTICIPANTSn423 adult male clients with modified depression (PHQ-8 score≥10).nnnINTERVENTIONSnDepression collaborative care implementation using community engagement and planning (CEP) across programs compared with the more-traditional individual program, technical assistance (Resources for Services, RS).nnnMAIN OUTCOME MEASURESnDepressive symptoms (PHQ-8 score), mental health-related quality of life (MHRQL), mental wellness, services utilization and settings.nnnRESULTSnAt screening, levels of probable depression were moderate to high (17.5%-47.1%) among men across services sectors. Intervention effects on primary outcomes (PHQ-8 score and MHRQL) did not differ. Men in CEP compared with RS had improved mental wellness (OR 1.85, 95% CI 1.00-3.42) and reduced hospitalizations (OR .40, 95% CI .16-.98), with fewer mental health specialty medication visits (IRR 0.33, 95% CI .15-.69), and a trend toward greater faith-based depression visits (IRR 2.89, 95% CI .99-8.45).nnnCONCLUSIONSnExploratory sub-analyses suggest that high rates of mainly minority men in under-resourced communities have high prevalence of depression. A multi-sector coalition approach may hold promise for improving community-prioritized outcomes, such as mental wellness and reduced hospitalizations for men, meriting further development of this approach for future research and program design.

Maintaining Internal Validity in Community Partnered Participatory Research: Experience from the Community Partners in Care Study

ObjectivenWith internal validity being a central goal of designed experiments, we seek to elucidate how community partnered participatory research (CPPR) impacts the internal validity of public health comparative-effectiveness research.nnnMethodsnCommunity Partners in Care (CPIC), a study comparing a community-coalition intervention to direct technical assistance for disseminating depression care to vulnerable populations, is used to illustrate design choices developed with attention to core CPPR principles. The study-design process is reviewed retrospectively and evaluated based on the resulting covariate balance across intervention arms and on broader peer-review assessments. Contributions of the CPIC Council and the studys design committee are highlighted.nnnResultsnCPPR principles contributed to building consensus around the use of randomization, creating a sampling frame, specifying geographic boundaries delimiting the scope of the investigation, grouping similar programs into pairs or other small blocks of units, collaboratively choosing random-number-generator seeds to determine randomized intervention assignments, and addressing logistical constraints in field operations. Study protocols yielded samples that were well-balanced on background characteristics across intervention arms. CPIC has been recognized for scientific merit, has drawn attention from policymakers, and has fueled ongoing research collaborations.nnnConclusionsnCreative and collaborative fulfillment of CPPR principles reinforced the internal validity of CPIC, strengthening the studys scientific rigor by engaging complementary areas of knowledge and expertise among members of the investigative team.

Participation in training for depression care quality improvement

Depressive disorders are leading causes of disability in the United States with racial disparities in access to, quality and outcomes of care in under-resourced communities.1-7 Primary care, depression quality improvement programs using team-based, chronic disease management can improve quality and care outcomes for depressed adults, including racial and ethnic minorities.8-17 Under healthcare reform, Medicaid behavioral health homes incentivize partnerships among healthcare, mental health, and social-community agencies (e.g. parks, senior centers), by noting “ Services must include prevention and health promotion, healthcare, mental health and substance use, and long-term care services, as well as linkages to community supports and resources.”18 However, few guidelines exist to organize diverse agencies into systems supporting chronic disease management. Also, no studies exist comparing the effects of alternative training approaches for depression quality improvement with diverse providers from healthcare and social-community programs. n nThis study analyzes data from Community Partners in Care (CPIC), a group-level, randomized, comparative-effectiveness study of two implementation approaches for evidence-based, depression quality improvement toolkits adapted for diverse healthcare and social-community settings. One implementation approach relies on more traditional technical assistance to individual programs (Resources for Services, RS). The other (Community Engagement and Planning, CEP) used community-partnered, participatory research (CPPR) principles to support collaborative planning across programs to implement the same depression care toolkits through a network.19-25 Programs randomized to each approach included healthcare and social-community programs.20-21 Six-month follow-up revealed that relative to RS, CEP improved depressed clients’ mental health-related quality of life, increased physical activity, and reduced homelessness risk factors; while reducing behavioral health hospitalizations and specialty medication visits, and increasing depression services use in primary care/public health, faith-based and park/community center programs with continued effects on mental health-related quality of life at 12-months.20,25 This study focuses on CPICs main intervention effects for primary program (i.e. program training participation) and staff-level (i.e. total training hours) outcomes, participation in evidence-based, depression quality improvement trainings. We hypothesized that CEP would lead to a broader range of staff training options than RS. To determine what types of organizations would participate in trainings, we compared interventions’ effects by program type (i.e. healthcare versus social-community). Based on prior work, we hypothesized that CEP relative to RS would increase mean hours of training participation, especially for social-community programs where such training is novel.26-28 To inform future depression quality improvement dissemination efforts in safety-net communities, we conducted exploratory analyses of interventions’ effects on staff training participation for each depression quality improvement component and by services sector.OBJECTIVEnCommunity engagement and planning (CEP) could improve dissemination of depression care quality improvement in underresourced communities, but whether its effects on provider training participation differ from those of standard technical assistance, or resources for services (RS), is unknown. This study compared program- and staff-level participation in depression care quality improvement training among programs enrolled in CEP, which trained networks of health care and social-community agencies jointly, and RS, which provided technical support to individual programs.nnnMETHODSnMatched programs from health care and social-community service sectors in two communities were randomly assigned to RS or CEP. Data were from 1,622 eligible staff members from 95 enrolled programs. Primary outcomes were any staff trained (for programs) and total hours of training (for staff). Secondary staff-level outcomes were hours of training in specific depression collaborative care components.nnnRESULTSnCEP programs were more likely than RS programs to participate in any training (p=.006). Within health care sectors, CEP programs were more likely than RS programs to participate in training (p=.016), but within social-community sectors, there was no difference in training by intervention. Among staff who participated in training, mean training hours were greater among CEP programs versus RS programs for any type of training (p<.001) and for training related to each component of depression care (p<.001) except medication management.nnnCONCLUSIONSnCEP may be an effective strategy to promote staff participation in depression care improvement efforts in underresourced communities.

Depression Care Training Participation: Randomized Trial of Community Engagement or Technical Support

Depressive disorders are leading causes of disability in the United States with racial disparities in access to, quality and outcomes of care in under-resourced communities.1-7 Primary care, depression quality improvement programs using team-based, chronic disease management can improve quality and care outcomes for depressed adults, including racial and ethnic minorities.8-17 Under healthcare reform, Medicaid behavioral health homes incentivize partnerships among healthcare, mental health, and social-community agencies (e.g. parks, senior centers), by noting “ Services must include prevention and health promotion, healthcare, mental health and substance use, and long-term care services, as well as linkages to community supports and resources.”18 However, few guidelines exist to organize diverse agencies into systems supporting chronic disease management. Also, no studies exist comparing the effects of alternative training approaches for depression quality improvement with diverse providers from healthcare and social-community programs. n nThis study analyzes data from Community Partners in Care (CPIC), a group-level, randomized, comparative-effectiveness study of two implementation approaches for evidence-based, depression quality improvement toolkits adapted for diverse healthcare and social-community settings. One implementation approach relies on more traditional technical assistance to individual programs (Resources for Services, RS). The other (Community Engagement and Planning, CEP) used community-partnered, participatory research (CPPR) principles to support collaborative planning across programs to implement the same depression care toolkits through a network.19-25 Programs randomized to each approach included healthcare and social-community programs.20-21 Six-month follow-up revealed that relative to RS, CEP improved depressed clients’ mental health-related quality of life, increased physical activity, and reduced homelessness risk factors; while reducing behavioral health hospitalizations and specialty medication visits, and increasing depression services use in primary care/public health, faith-based and park/community center programs with continued effects on mental health-related quality of life at 12-months.20,25 This study focuses on CPICs main intervention effects for primary program (i.e. program training participation) and staff-level (i.e. total training hours) outcomes, participation in evidence-based, depression quality improvement trainings. We hypothesized that CEP would lead to a broader range of staff training options than RS. To determine what types of organizations would participate in trainings, we compared interventions’ effects by program type (i.e. healthcare versus social-community). Based on prior work, we hypothesized that CEP relative to RS would increase mean hours of training participation, especially for social-community programs where such training is novel.26-28 To inform future depression quality improvement dissemination efforts in safety-net communities, we conducted exploratory analyses of interventions’ effects on staff training participation for each depression quality improvement component and by services sector.OBJECTIVEnCommunity engagement and planning (CEP) could improve dissemination of depression care quality improvement in underresourced communities, but whether its effects on provider training participation differ from those of standard technical assistance, or resources for services (RS), is unknown. This study compared program- and staff-level participation in depression care quality improvement training among programs enrolled in CEP, which trained networks of health care and social-community agencies jointly, and RS, which provided technical support to individual programs.nnnMETHODSnMatched programs from health care and social-community service sectors in two communities were randomly assigned to RS or CEP. Data were from 1,622 eligible staff members from 95 enrolled programs. Primary outcomes were any staff trained (for programs) and total hours of training (for staff). Secondary staff-level outcomes were hours of training in specific depression collaborative care components.nnnRESULTSnCEP programs were more likely than RS programs to participate in any training (p=.006). Within health care sectors, CEP programs were more likely than RS programs to participate in training (p=.016), but within social-community sectors, there was no difference in training by intervention. Among staff who participated in training, mean training hours were greater among CEP programs versus RS programs for any type of training (p<.001) and for training related to each component of depression care (p<.001) except medication management.nnnCONCLUSIONSnCEP may be an effective strategy to promote staff participation in depression care improvement efforts in underresourced communities.

12-month outcomes of community engagement versus technical assistance to implement depression collaborative care

Depression and depressive symptoms are main causes of disability in the United States (1, 2), where racial disparities persist in access to and quality and outcomes of care (39). Depression collaborative care provided in primary care settings can improve quality and outcomes of care for depressed adults while reducing outcome disparities by race (1018), but safety-net primary care settings generally have limited capacity for full implementation of collaborative care (1921). Encouraging safety-net clinics to collaborate with other key agencies (for example, social services or faith-based organizations) using community engagement (2226) may support successful implementation of depression collaborative care across underresourced communities. Community Partners in Care (CPIC) was designed to compare the effects of 2 depression collaborative care implementation approaches: 1) community engagement and planning (CEP), which supports collaborative planning and implementation across myriad community programs, and 2) more traditional resources for services (RS) models, which rely on time-limited expert technical assistance for collaborative care to individual programs (2729). Earlier studies concluded that at 6 months, compared with RS, CEP reduced the probability of poor mental healthrelated quality of life (MHRQL) among depressed clients, increased their physical activity, and reduced risk factors for homelessness (2830). Moreover, CEP reduced behavioral health hospitalizations and specialty medication visits among visitors to mental health specialists while increasing use of primary care, faith-based, and park-based services for depression among such clients. To our knowledge, CPIC is the first randomized U.S. study of the added value of CEP beyond more traditional expert assistance to individual programs and the first depression collaborative care study to span the health care and social community sectors. We examined the effects of CEP over RS on poor MHRQL and services use at 6 and 12 months, as well as changes in outcomes from baseline to 6 months and baseline to 12 months. We hypothesized that compared with RS, CEP would decrease the proportion of clients with poor MHRQL at 12 months. Methods Study Design Community Partners in Care is a group-level randomized comparative effectiveness trial comparing CEP with RS. Both interventions were designed to provide extensive depression collaborative care training to mental health, medical, and community-based agencies. The RS model provided preset, time-limited training to individual agencies, whereas CEP encouraged these diverse agencies to develop a strategy and training plan to jointly provide care for depression (Table 1 in Data Supplement 4). The interventions and study methods are described elsewhere (2831). Data Supplement 4. Data Supplement The study and CEP intervention were guided by community-partnered participatory research principles (3235), a community-based participatory research variant (36, 37) promoting equal authority among community and academic partners (Data Supplement 1). The study council, co-led by the University of California, Los Angeles (UCLA); RAND Corporation; Healthy African American Families II; Behavioral Health Services; and QueensCare Health and Faith Partnership supported workgroups and community forums for study input (2731, 38, 39). Data Supplement 1. Community Partners in Care: 6-Month Client Outcomes Setting The study took place in 2 Los Angeles County communities: South Los Angeles and Hollywood-Metro. These communities have high rates of poverty and avoidable hospitalizations and low rates of insurance (4042). We hosted community meetings to identify community-based settings that support vulnerable depressed populations, with the aim of oversampling from these settings, which included mental health, primary care, public health, substance abuse, and social services; faith-based programs; parks; senior centers; hair salons; and exercise clubs. South Los Angeles partners emphasized inclusion of large samples of substance abuse clients and African American persons, whereas Hollywood-Metro emphasized homeless clients and seniors. Participants and Randomization Programs We began by identifying a pool of relevant agencies and organizations through county program lists and nominations from community partners. We then contacted each to assess interest, eligibility, and enrollment. This process resulted in a pool of 60 potentially eligible agencies with 194 programs. Programs were eligible if they served 15 or more clients per week, had 1 or more staff members, and did not focus exclusively on psychotic disorders or home services. A total of 133 of these 194 programs were potentially eligible. Within each community, programs or clusters of smaller programs were paired on the basis of location, service sector, size, population served, services provided, and funding streams; 2 larger agencies were their own single stratum. Within pairs, one program or cluster was randomly assigned to CEP and the other to RS (43). A statistician uninvolved with recruitment supported council members in producing seed numbers for randomization (44). The 133 programs were randomly assigned to the interventions (65 to RS and 68 to CEP) (Figure). After randomization, RAND staff who were blinded to assignment conducted site visits to finalize enrollment; 20 programs were determined ineligible, 18 declined participation, and 95 programs from 50 consenting agencies were enrolled (46 in RS and 49 in CEP) (Figure). Figure. Study flow diagram. Five programs (2 in the RS group and 3 in the CEP group) had no clients with data for outcome analysis. CEP = community engagement and planning; RS = resources for services. Administrators were informed of intervention status by letter. Participating and nonparticipating agencies were similar in terms of clients age, sex, and race; population density; and client income by ZIP code (each P> 0.10), as determined by analysis of census tract data. Clients To achieve a 6-month follow-up sample of 780 depressed clients, we planned to enroll 557 to 600 clients per intervention (assuming 65% to 70% retention). We powered the study to identify a detectable effect size ranging from 0.20 to 0.22 and a percentage point difference between groups ranging from 9.98 to 10.91, assuming 80% power with a 2-sided value of 0.05 and an intraclass correlation coefficient assumed to range from 0.00 to 0.02 (43, 45, 46). Within programs, clients were screened in waiting rooms (approached consecutively) or at events (approached randomly) from March to November 2010. Allocating 2 to 3 days per program, RAND staff who were blinded to intervention status approached 4649 adults (aged 18 years) allocating 2 to 3 days per program; of these, 4440 (95.5%) agreed to screening. Eligibility was limited to clients who provided contact information and had at least mild depressive symptoms, as indicated by a score of 10 or greater on the 8-item Patient Health Questionnaire (47). Of 4440 persons screened, 1322 (29.8%) were eligible; 1246 (94.3%) of eligible persons enrolled, a high rate for such studies (11, 14, 16). Between April 2010 and January 2011, 981 clients (79% of those enrolled) completed a baseline telephone survey conducted by RAND survey staff who were blinded to intervention. Of 1093 participants approached for 6-month telephone follow-up surveys between November 2010 and August 2011, 759 (70%) participated. Of 974 participants approached for 12-month telephone follow-up surveys between May 2011 and March 2012, 733 (75%) participated. Data Supplement 2 shows the survey questions. We did not attempt to contact 272 participants because their survey response at baseline (n= 153) or 6 months (n= 119) was final refusal, ill, incarcerated, unable to contact, or dead. Data Supplement 2. CPIC Client Baseline Questionnaire Our analytic sample comprises 1018 individuals (77% of eligible; 82% of enrolled) who completed 1 or more surveys at baseline, 6 months, or 12 months (Figure). Characteristics of persons who completed the 12-month survey differed from those did not complete it by intervention: The RS group had significantly higher nonresponse rates among men, clients recruited from substance abuse programs, and those with no health insurance. In the CEP group, responders were more likely to have lower family income and to be African American (Tables B2 to B4 in Data Supplement 3). Data Supplement 3. Supplementary Technical Appendix Interventions The compared interventions, CEP and RS, were designed to expose a range of health care and social community agencies to the same depression collaborative care toolkits. Between December 2009 and July 2011, CEP supported program administrators to work as councils: one in Hollywood-Metro and another in South Los Angeles. Each council met biweekly over 5 months to adapt depression care toolkits and trainings to each community. In addition, each council developed plans for a coordinated services network across health care and social community programs to support depressed adults. Planning was co-led by community and academic council members following community-partnered participatory research principles (for example, shared authority and 2-way knowledge exchange) (39) (Table 1 in Data Supplement 4). In RS, technical assistance was offered to assigned programs for the depression care toolkits by using a train-the-trainer model. Between December 2009 and July 2010, training was conducted through 10 webinars plus site visits to primary care for each community (39). Trainers included a nurse care manager, a cognitive-behavioral therapist who was a licensed psychologist, 3 board-certified psychiatrists for medication management, and community service administrators to support participation and cultural competence. The CPIC Council modified depression collaborative care toolkits (48) that supported clinician assessment, medication