Zvi D. Gellis

Outcomes of a Telehealth Intervention for Homebound Older Adults With Heart or Chronic Respiratory Failure: A Randomized Controlled Trial

PURPOSE  Telehealth care is emerging as a viable intervention model to treat complex chronic conditions, such as heart failure (HF) and chronic obstructive pulmonary disease (COPD), and to engage older adults in self-care disease management.  DESIGN AND METHODS  We report on a randomized controlled trial examining the impact of a multifaceted telehealth intervention on health, mental health, and service utilization outcomes among homebound medically ill older adults diagnosed with HF or COPD. Random effects regression modeling was used, and we hypothesized that older adults in the telehealth intervention (n = 51) would receive significantly better quality of care resulting in improved scores in health-related quality of life, mental health, and satisfaction with care at 3 months follow-up as compared with controls (n = 51) and service utilization outcomes at 12 months follow-up.  RESULTS  At follow-up, the telehealth intervention group reported greater increases in general health and social functioning, and improved in depression symptom scores as compared with usual care plus education group. The control group had significantly more visits to the emergency department than the telehealth group. There was an observed trend toward fewer hospital days for telehealth participants, but it did not reach significance at 12 months.  IMPLICATIONS  Telehealth may be an efficient and effective method of systematically delivering integrated care in the home health sector. The use of telehealth technology may benefit homebound older adults who have difficulty accessing care due to disability, transportation, or isolation.

Integrated Telehealth Care for Chronic Illness and Depression in Geriatric Home Care Patients: The Integrated Telehealth Education and Activation of Mood (I-TEAM) Study

To evaluate an integrated telehealth intervention (Integrated Telehealth Education and Activation of Mood (I‐TEAM)) to improve chronic illness (congestive heart failure, chronic obstructive pulmonary disease) and comorbid depression in the home healthcare setting.

Problem-Solving Therapy for Depression in Adults: A Systematic Review.

Objectives: This article presents a systematic review of the evidence on problem-solving therapy (PST) for depressive disorders in noninstitutionalized adults. Method: Intervention studies using randomized controlled designs are included and methodological quality is assessed using a standard set of criteria from the Cochrane Collaborative Review Initiative. Results: Twenty-two studies investigating PST for adult depression are compiled and examined. Studies differ in scope and methodological rigor. Sample sizes vary widely; all study outcomes include depression measures; problems in masking of group assignment and randomization are noted. Conclusions: Mixed evidence for PST as a depression treatment is found. The combined use of PST and antidepressant treatment has more favorable outcomes compared with PST alone for social work practice.

Meta-Analysis of the Effect of Cardiac Rehabilitation Interventions on Depression Outcomes in Adults 64 Years of Age and Older

Heart disease is a major cause of hospitalization and is associated with greater impairment than arthritis, diabetes mellitus, or lung disease. Depression is prevalent and a serious co-morbidity in heart disease with negative consequences including higher levels of chronic physical illness, decreased psychological well-being, and increased health care costs. The objective of the study was to examine with meta-analysis the impact of community-based cardiac rehabilitation (CR) treatment on depression outcomes in older adults. Randomized controlled trials comparing patients (≥64 years old) receiving CR to cardiac controls were considered. Meta-analyses were based on 18 studies that met inclusion criteria, comprising 1,926 treatment participants and 1,901 controls. Effect sizes (ESs) ranged from -0.39 (in favor of control group) to 1.09 (in favor of treatment group). Mean weighted ES was 0.28, and 11 studies showed positive ESs. Meta-analysis suggests that most CR programs delivered in the home can significantly mitigate depression symptoms. Tailored interventions combined with psychosocial interventions are likely to be more effective in decreasing depression in older adults with heart disease than usual care.

Assessment of a Brief CES-D Measure for Depression in Homebound Medically Ill Older Adults

Depressive symptoms are highly prevalent among medically ill homebound elderly and are associated with significant functional decline, lower quality of life, and increased health care utilization. Despite this, depression is generally underdiagnosed and undertreated among medically ill homebound older adults. The objective of this study was to determine the validity of a brief depression measure (CES-D) and examine the nature of depressive symptoms reported by the older sample. Using confirmatory factor and rating scale analysis, the factor structure of responses in a cross-sectional home care sample (n = 618) was examined with a further analysis of item responses from identified urban and rural subsamples. Radloffs (1977) four-factor depression model fit the data well. Some symptom items were expressed differently and this offers an opportunity to understand the unique clinical aspects of depression in homebound older adults.

A Neighborhood Naturally Occurring Retirement Community: Views From Providers and Residents

Maximizing quality of life for older adults poses challenges for formal service providers. One strategy to identify and address factors influencing health/mental health and promoting autonomy of community-dwelling older people is through a Neighborhood Naturally Occurring Retirement Community (NNORC), a community development model of formal and informal home and community-based support. This article uses qualitative methods to report on critical themes generated from an initial evaluation of an NNORC using individual interviews with community partners that developed the program and Resident Council members living in the NNORC community. Findings reveal the need to support older adults aging in place, the importance of informal systems of care, access to trustworthy concrete service providers, and improved models of collaboration.

Randomized Controlled Trial of Problem-Solving Therapy for Minor Depression in Home Care

Objective: Data are presented from a pilot research program initiated to develop, refine, and test the outcomes of problem-solving therapy that targets the needs of older adults with minor depression in home care settings. Method: A pilot randomized clinical trial compares the impact of problem-solving therapy for home care to treatment as usual in a sample of older, medically ill home care patients. Compared with 32 older home care participants randomized to the treatment as usual condition, 30 older home care participants in an intervention condition received brief problem-solving therapy. Results: Outcome data suggest significant improvements in depression symptomatology and problem-solving abilities after problem-solving therapy for home care, relative to treatment as usual. The experimental group was also more satisfied with treatment as compared to the control condition. Conclusion: Authors discuss results in terms of the “real-world” social work applicability of this psychosocial treatment for late-life depression.

A systematic review of community-based health interventions on depression for older adults with heart disease.

Purpose: This systematic review examined the effectiveness of community-based heart-health interventions on depression outcomes among homebound elderly (64 years and older) with heart disease. Design and Methods: A comprehensive literature search and meta analysis was performed to evaluate randomized controlled trials examining outpatient or home-based interventions. Methodological quality was assessed by standard criteria developed by the Cochrane Collaborative Initiative. Results: Fifteen studies met our inclusion criteria and all measured depression outcomes. Studies differed in scope and methodological rigor and sample sizes varied widely. Problems in treatment fidelity and masking of group assignment were noted. Great variability was found in depression outcomes due to the differences in methodology and intervention. Five studies reported significant treatment effect on depression; three of those employed home-based interventions and two were outpatient-clinic interventions. Ten studies were included in the meta analysis and the effect sizes (ESs) ranged from −0.39 (in favor of control group) to 0.65 (in favor of treatment group). The mean weighted ES was 0.11 and six studies showed positive ESs. Implications: Mixed evidence for community-based heart disease interventions on depression outcomes was found. Future research should include sub-analysis of ESs of interventions on depression outcomes by different demographic characteristics of the study sample, common depression outcome measures, and different follow-up periods.

Problem-solving therapy to improve depression scores among older hemodialysis patients: a pilot randomized trial.

AIMS Depression is common among dialysis patients and is associated with adverse outcomes. Problem-solving therapy (PST) is effective for treating depression in older patients with chronic illness, but its effectiveness has never been reported in hemodialysis (HD) patients. We investigated the feasibility and satisfaction of PST and its impact on depression scores among older HD patients. METHODS Patients at least 60 years of age receiving maintenance HD at a single outpatient dialysis center were eligible for the study. Randomized patients received either 6 weeks of PST from a licensed renal social worker or usual care. This study modeled the staff-patient ratio standard of most dialysis clinics, and therefore only one social worker provided the interventions. Study outcomes included feasibility (successful completion of 6 weekly sessions) and patient satisfaction with PST as well as impact on depression scores (between-group comparison of mean Beck depression inventory (BDI) and Patient health questionnaire-9 (PHQ-9) scores at 6 weeks, and of mean change-from-baseline scores). RESULTS The recruitment rate was 92% (35/38). All subjects randomized to the intervention arm (n = 17) and who initiated PST (n = 15) completed the study, and all reported overall satisfaction with the intervention. 87% reported that PST helped them to better solve problems and improved their ability to cope with their medical condition. At 6 weeks, there were no significant differences in mean BDI and PHQ scores between the usual care and the intervention group (BDI 11.3 vs. 9.3, p = 0.6; PHQ 5.7 vs. 3.3, p = 0.1). Mean change-from-baseline depression scores were significantly improved in the intervention group relative to the control group (change in BDI 6.3 vs.- 0.6, p = 0.004; change in PHQ 7.2 vs. 0.3, p < 0.001). CONCLUSIONS The results demonstrate that PST is feasible in the dialysis unit setting, acceptable to patients, and may positively impact depression among maintenance hemodialysis patients.

Integrating Mental Health Parity for Homebound Older Adults Under the Medicare Home Health Care Benefit

Despite high rates of mental illness, very few homebound older adults receive treatment. Comorbid mental illness exacerbates physical health conditions, reduces treatment adherence, and increases dependency and medical costs. Although effective treatments exist, many home health agencies lack capacity to effectively detect and treat mental illness. This article critically analyzes barriers within the Medicare home health benefit that impede access to mental health treatment. Policy, practice, and research recommendations are made to integrate mental health parity in home health care. In particular, creative use of medical social work can improve detection and treatment of mental illness for homebound older adults.