Improving Care for Late-Life Depression Through Partnerships With Community-Based Organizations: Results From the Care Partners Project

OBJECTIVES

Collaborative care (CC) has demonstrated effectiveness for improving late-life depression in primary care, but clinics offering this service can find it challenging to address unmet social needs that may be contributing to their patients' depression. Clinics may benefit from better coordination and communication with community-based organizations (CBO) to strengthen depression treatment and to address unmet social needs. We evaluated the feasibility of adding a CBO to enhance standard collaborative care and the impact of such partnered care on older adults.

DESIGN

Multisite, prepost evaluation.

SETTING

Eight (n = 8) partnerships between primary care clinics and community-based organizations in California.

PARTICIPANTS

A total of 707 depressed older adults (60 years or older) as evidenced by having a score of 10 or more on the Patient Health Questionnaire (PHQ-9) received care under the Care Partners project.

INTERVENTION

A CBO partner was added to augment CC for late-life depression in primary care.

MEASUREMENTS

The PHQ-9 was used to identify depressed older adults and to monitor depression symptom severity during a course of care.

RESULTS

At baseline, the average PHQ-9 depression score across the partnerships was 15, indicating moderate depression severity. Participating patients saw an average 7-point reduction in their PHQ-9 score, baseline to last score assessed, with nearly half of all participants (48.4%) experiencing a 50% or greater improvement from their baseline score.

CONCLUSIONS

Our findings suggest that partnering with a community-based organization is a feasible and effective way for primary care clinics to address late-life depression in their patients.

How do family caregivers of older adults cope with relationship strain?

OBJECTIVE

Studies of families' experiences with caregiving to older adults most often focus on overall burden and stress. Yet, caregiving is also a type of relationship, and the onset of caregiving can contribute to relationship strain between care partners. Despite implications for both care partners, little is known about how caregivers cope with caregiving relationship strain.

METHODS

The authors conducted nine focus groups and 8 interviews with a purposeful sample of racially and ethnically diverse family caregivers in Los Angeles. Conventional content analysis was applied to transcripts to identify how caregivers cope with relationship strain.

RESULTS

Analyses revealed four overall coping approaches to manage relationship strain: (1) Self-Care; (2) Adapting Behaviors, (3) Adapting Feelings and Cognitions, and (4) Help and Support. Selected strategies likely vary by care recipient condition. For example, caregivers for persons living with dementia emphasize adapting their own behaviors and feelings, rather than trying to change their loved one's behaviors.

CONCLUSIONS

Findings suggest that caregivers cope with relationship strain using both interpersonal tension and care management strategies. We also identified possible variations by care recipient condition and caregiver race and ethnicity. These results suggest a need for interventions focused on caregiver coping should also be tested for effects on relationship strain.

"We are the sun for our community:" Partnering with community health workers/promotores to adapt, deliver and evaluate a home-based collaborative care model to improve equity in access to quality depression care for older U.S. Latino adults who are underserved

Background

While depression is a leading cause of poor health, less than half of older adults receive adequate care. Inequities in both access and outcomes are even more pronounced for socially disadvantaged older adults. The collaborative care model (CCM) has potential to reduce this burden through community-based organizations (CBOs) who serve these populations. However, CCM has been understudied in diverse cultural and resource-constrained contexts. We evaluated the implementation and effectiveness of PEARLS, a home-based CCM adapted with and for community health workers/promotores (CHWs/Ps).

Methods

We used an instrumental case study design. Our case definition is a community-academic partnership to build CHW/P capacity for evidence-based depression care for older U.S. Latino adults in the Inland Empire region of California (2017-2020). We aimed to understand adaptations to fit local context; acceptability, feasibility, and fidelity; clinical effectiveness; and contextual determinants of implementation success or failure. Data sources included quantitative and qualitative administrative and evaluation data from participants and providers. We used descriptive statistics and paired t-tests to characterize care delivery and evaluate effectiveness post-intervention, and deductive thematic analysis to answer other aims.

Findings

This case study included 152 PEARLS participants and nine data sources (N = 67 documents). The CBO including their CHWs/Ps partnered with the external implementation team made adaptations to PEARLS content, context, and implementation strategies to support CHWs/Ps and older adults. PEARLS was acceptable, feasible and delivered with fidelity. Participants showed significant reductions in depression severity at 5 months (98% clinical response rate [mean (SD), 13.7 (3.9) drop in pre/post PHQ-9; p < 0.001] and received support for 2.6 social needs on average. PEARLS delivery was facilitated by its relative advantage, adaptability, and trialability; the team's collective efficacy, buy-in, alignment with organization mission, and ongoing reflection and evaluation during implementation. Delivery was challenged by weak partnerships with clinics for participant referral, engagement, reimbursement, and sustainability post-grant funding.

Discussion

This case study used existing data to learn how home-based CCM was adapted by and for CHWs/Ps to reduce health inequities in late-life depression and depression care among older Latino immigrants. The CBOs and CHWs/Ps strong trust and rapport, addressing social and health needs alongside depression care, and regular internal and external coaching and consultation, appeared to drive successful implementation and effectiveness.

Caregiver Mental Health Outcomes: Are There Differences Across Generations?

Informal caregivers are a critical component of support for the rapidly aging population. Previous studies have addressed the effects of caregiving on mental health. However, they have not focused on differences among generational cohorts of caregivers of older adults, i.e., Millennial (born 1981-1996), Generation X (born 1965-1980), Baby Boomer (born 1946-1964), and Silent Generation (born 1928-1945). As the Millennial caregiver population grows in parallel with older adults and their increased needs, we must better understand Millennial responses to caregiving. Millennial caregivers provide a similar intensity of care as Baby Boomers in terms of hours per week but are more likely to be fully employed (40+ hours per week or more). We used caregiver data from the nationally representative Centers for Disease Control’s Behavioral Risk Factor Surveillance System (BRFSS) survey from 2015-2017 to conduct negative binomial regression (n=50,745). Data analysis indicates that Millennial caregivers have an incidence rate ratio of 1.22 times more self-reported days of “stress, depression, and/or problems with emotions” compared to Generation X caregivers (p<0.01); 1.64 times compared to Baby Boomers (p<0.001); and 2.38 times compared to Silent Generation caregivers (p<0.001). Generational differences show that Millennial caregivers may have different needs than older generations of caregivers. Rather than assuming that the policies and interventions designed for older generations of caregivers will fit younger generations, implications of this work can help inform: 1) the design of programs to support caregivers’ mental health, and 2) policy considerations that address the unique needs of a younger caregiver population.

Complexity in partnerships: A qualitative examination of collaborative depression care in primary care clinics and community-based organisations in California, United States

Partnering across health clinics and community organisations, while worthwhile for improving health and well-being, is challenging and time consuming. Even partnerships that have essential elements for success in place face inevitable challenges. To better understand how cross-organisational partnerships work in practice, this paper examines collaborations between six primary care clinics and community-based organisations in the United States that were part of an initiative to address late-life depression using an enhanced collaborative care model (Archstone Foundation Care Partners Project). As part of an evaluation of the Care Partners Project, 54 key informant interviews and 10 focus groups were conducted from 2015 to 2017. Additionally, more than 80 project-related documents were reviewed. Qualitative thematic analysis was used to code the transcripts and identify prominent themes in the data. Examining clinic and community organisation partnerships in practice highlighted their inherent complexity. The partnerships were fluid and constantly evolving, shaped by a multiplicity of perspectives and values, and vulnerable to unpredictability. Care Partners sites negotiated the complexity of their partnerships drawing upon three main strategies: adaptation (allowing for flexibility and rapid change); integration (providing opportunities for multi-level partnerships within and across organisations) and cultivation (fostering a commitment to the partnership and its value). These strategies provided opportunities for Care Partners collaborators to work with the inherent complexity of partnering. Intentionally acknowledging and embracing such complexity rather than trying to reduce or avoid it, may allow clinic and community collaborators to strengthen and sustain their partnerships.

STRENGTHENING LATE-LIFE DEPRESSION COLLABORATIVE CARE THROUGH COMMUNITY ENGAGEMENT: CARE PARTNERS INITIATIVE

Despite the availability of effective treatments for late life depression, many older adults with depression either do not access or fully engage in treatment. The goal of this study was to examine the feasibility and two-year outcomes from an Archstone Foundation funded Care Partners Initiative to strengthen depression care for adults 65 years of age and older. Seven sites throughout California implemented evidence-based collaborative care through partnerships between primary care organizations, community-based organizations (CBOs), and families of older adults with depression. Evaluation used a mixed-methods approach incorporating both qualitative and quantitative data. Of the seven sites, six formed partnerships between primary care clinics and CBOs and one site only focused on engaging family members in treatment. In the first two years, 274 patients were enrolled and rates of depression improvement were comparable to prior depression care effectiveness trials. Overall, 49% of patients at CBO sites interacted 3+ times with CBO staff/clinicians, while at the family site, 79% of patients had 3+ contacts including a family member. Using data from key informant interviews, focus groups, and site progress documents, seven core components were identified that facilitated successful implementation and delivery of partnered collaborative care, including three foundational components: strong stakeholder buy-in, effective patient engagement, and the promotion of depression treatment as a core value across organizations. Multiple complexities of partnering between primary care clinics and CBOs or families were identified. Challenges and lessons learned from this initiative will also be discussed.

SUPPORTING FAMILY CAREGIVERS: HOW DOES RELATIONSHIP STRAIN OCCUR IN CAREGIVING DYADS? A QUALITATIVE STUDY

Family members and spouses are usually the primary caregivers for older adults. Providing direct care can be stressful, strenuous, and time-consuming for caregivers, potentially leading to frustration and anger towards care recipients. This can be detrimental to the relationship quality of the caregiving dyad. Though caregiver strain and burden have been extensively studied, there is limited information on the development of relationship strain. To explore how relationship strain occurs between caregivers and care recipients, 8 focus groups (N=62) and 8 semi-structured telephone interviews were conducted with caregivers in Los Angeles, inquiring about relationship quality with their care recipients and when frustration and anger occurs. Inductive coding was used to create coding schemas. Findings showed that most caregivers reported relationship strain occurring after taking on the caregiving role, and frustration and anger arose when providing ADLs, especially during bathing and toileting. Although these caregivers had initially experienced strain in their relationships, a recurring theme that emerged was that they developed strategies to decrease frustration and anger and improve the quality of their relationships with their care recipients. Direct communication with caregivers is important in designing a structured and effective intervention. These findings help inform an intervention for new caregivers to help them identify what can lead to relationship strain, as well as teach them reliable strategies to manage frustration and anger towards their care recipients.

SUPPORTING FAMILY CAREGIVERS: HOW DO CAREGIVERS OF OLDER ADULTS COPE WITH ROLE STRAIN? A QUALITATIVE STUDY

Qualitative research on positive coping approaches actually used by caregivers can inform interventions that can be feasibly implemented. Absent from previous qualitative research is how caregivers respond to strain in the relationship, specifically. Eight focus groups were conducted with a purposeful sample of racially and ethnically diverse family caregivers in Los Angeles (n=75). An additional 8 in-depth follow-up interviews were conducted. Content analysis was used to understand the mechanisms employed by caregivers to cope with strain and tension in the caregiving relationship. Preliminary results revealed twenty-two individual themes, which were subsequently grouped into four main superordinate themes: 1) Self-care; 2) Adaptation of behaviors and feelings; 3) Seeking and utilizing assistance and respite; and 4) Education and support groups. This work can help inform the design of programs to support caregivers and prevent potentially harmful behaviors, through understanding the experiences of caregivers in their own words.

What Are Strategies to Advance Policies Supporting Family Caregivers? Promising Approaches From a Statewide Task Force

Family caregivers are the cornerstone of the long-term supports and services infrastructure in the United States, yet they often contend with many challenges related to this role. Public policy has been slow to change, leaving many caregivers vulnerable to health and economic consequences. Using models of policy making, we identify barriers to advancing policies that support family caregivers and overcome policy drift. We draw on discussions from the California Task Force on Family Caregiving as it prepares state policy recommendations. Identified strategies include identification of caregivers in health care and workplace settings to promote political consciousness raising, collecting and reporting on data that frame caregiving as a policy problem, borrowing policies and language from overlapping fields to emulate their policy successes, and presenting supportive caregiver policies as solutions to other policy problems. By presenting specific strategic approaches to advance caregiving policies, we provide tools to address the growing gap between caregiver needs and policy responses.

Cost-effective upgrading of a biological wastewater treatment plant by using lamella separators with bypass operation

Based on a comprehensive cost analysis for the expansion of the Finnentrop WWTP, integration of lamella separators in the biological treatment stage was given priority as optimal solution to increase the solids concentration. The overall expansion project included the reconstruction of the former primary clarifier into a primary settling tank with short retention times and the use of the remaining volume for pre-denitrification. Four lamella separators were positioned in the existing carousel-type activated sludge tank. With the lamella assemblies ensuring it was possible to continue operation of the existing secondary settling tanks. To control an adequate solids concentration in the activated sludge tank and to avoid any overloading of the secondary settling tank, a newly developed bypass strategy was applied. With a controlled mixing of direct effluent from the lamella separators and the contents of the activated sludge tank, the solids concentration of the influent to the secondary settling tank could be maintained at a value of 2.2 kg/m(3). The lamella separator concept did not account for any significant changes in the sludge characteristics, and the overall elimination of nutrients and organic carbon was found to be excellent upon optimisation of the operational lamella strategy.

Phase II study of gefitinib and docetaxel for patients (pts) with advanced pancreatic adenocarcinoma (APC) progressing after first-line therapy. Final results

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Background: Gemcitabine is the standard-of-care for APC; the epidermal growth factor receptor (EGFR) inhibitor erlotinib is sometimes added to initial therapy. Pre-clinical data supports the addition of the EGFR inhibitor gefitinib to docetaxel, an agent with activity in APC. Because there is no standard treatment after gemcitabine failure, this combination was examined in a phase II study. Methods: Pts were required to have APC and have failed one prior treatment regimen; EGFR over-expression was not required. The initial docetaxel dose was 75 mg/m2 on day one every 21 days . Due to febrile neutropenia in 8 of 18 pts, the dose was reduced to 60 mg/m2. Gefitinib 250 mg/day orally was given continuously. Accrual of 41 pts was planned in a one-stage design to identify a targeted 50% improvement in median survival from 3.5 to 5.3 months (mo) by one-sided log-rank test (80% power, a = 0.05). Results: Forty five pts met eligibility and signed consent; 41 pts received treatment and were evaluable. Pt characteristics: 68% male, median age 63 yrs. (range 47 - 82). ECOG performance status (PS) 0 - 1 in all pts, except for 3 with PS of 2. Common treatment-related Grade 3 - 4 toxicities were: febrile neutropenia / infection in 11 pts (27%), with most events occurring at docetaxel dose of 75 mg/ m2 (8 of 18 pts); fatigue (7%), nausea (7%), diarrhea (5%) and vomiting (2%). Only 3 pts discontinued treatment due to toxicities and more than 2 cycles were administered to 40% of patients. The median survival was 4.7 mo (95% CI 2.9 - 5.7 mo). Time to progression was 1.8 months. There was one partial response (PR) and stable disease (SD) in 14 pts. Conclusion: The combination of gefitinib (250 mg/d) and docetaxel (60 mg/ m2) had evidence of some efficacy with one PR and SD in 14 pts. The median survival was 4.7 mo, somewhat lower than our intended target (5.3 mo). The tolerability and feasibility of second-line therapy for APC was demonstrated, and results of this study can be used as a benchmark to evaluate novel therapies in subsequent studies. (Supported by Astra Zeneca Pharmaceuticals)

No significant financial relationships to disclose.

Quantification of left ventricular function with an automated border detection system and comparison with radionuclide ventriculography

Quantification of 2-dimensional echocardiograms with a recently developed automated border detection (ABD) system provides on-line estimation of left ventricular (LV) function. Previous studies showed that short-axis cavity area measurements with the ABD system approximate manually traced cavity areas obtained with conventional 2-dimensional echocardiography. Further clinical validation needs a comparison of LV function between the ABD system and established methods. Fractional area change and ejection fraction measured by the ABD system were compared with ejection fraction measured by radionuclide ventriculography. Echocardiographic measurements were obtained from LV short-axis views at the level of the papillary muscles. Calculation of ejection fraction by the ABD system was based on an algorithm using a modified ellipsoid model. Forty-six patients underwent echocardiography on the same day as radionuclide ventriculography. Patients were included in the study if > or = 75% of the endocardium was visualized with conventional 2-dimensional echocardiography. Twenty-seven of 46 patients (59%) had a technically adequate, conventional echocardiogram. Fractional area change with the ABD system was highly correlated with ejection fraction from radionuclide ventriculography (r = 0.92; SEE 8.4%). Ejection fraction determined by the ABD system and radionuclide ventriculography also showed a strong linear relation in the 23 patients without severe wall motion abnormality (r = 0.90; SEE 9.5%). It is concluded that LV function measurements by the ABD system and radionuclide ventriculography have a strong linear relation.

[Necrotic pheochromocytoma presenting with shock and abdominal pain]

Pheochromocytoma is a rare tumor, the diagnosis of which is based on a history of hypertension, and symptoms, signs and laboratory data associated with increased release of catecholamines. The combination of pheochromocytoma and shock is uncommon, but when it does occur, is often associated with necrosis of the tumor. We report an unusual case of a patient whose clinical findings suggested fulminating septic shock. Only at postmortem was the diagnosis of pheochromocytoma made.

Diagnosis of recent myocardial infarction with quantitative backscatter imaging: preliminary studies

Acute myocardial ischemia and chronic myocardial infarction may be recognized with ultrasound tissue characterization techniques because of myocardial acoustic changes caused by reduced perfusion and/or collagen deposition. Our purpose was to study the acoustic properties of recent myocardial infarction when the predominating pathologic finding was myocardial edema and leukocytic infiltration. We used a new quantitative backscatter imaging system to study 18 patients 9 +/- 5 days after myocardial infarction (eight patients with anteroseptal myocardial infarction and 10 with inferior myocardial infarction) and 20 normal subjects. The cyclic variation of relative integrated backscatter (end-diastolic minus end-systolic) was calculated from on-line measurements. Standard parasternal long- and short-axis and apical four- and two-chamber views were obtained. In the anteroseptal myocardial infarction group, the cyclic variation of relative integrated backscatter was lower in the septum (1.5 +/- 1.6 dB) than in the posteroinferior wall (3.2 +/- 1.2 dB); however, the sample size of only three patients (of eight patients imaged) in the latter group prevented statistical comparison. The cyclic variation of relative integrated backscatter in the infarcted septum was less than the measurement obtained in the septum of the control group (4.3 +/- 2.4 dB, p less than 0.05). In the inferior infarction group, the cyclic variation of integrated backscatter in the posteroinferior wall (1.8 +/- 1.7 dB) was not significantly different from the measurement obtained in the septum (3.7 +/- 3.6 dB); however, the cyclic variation in the posteroinferior wall was significantly less than that obtained in the control group posteroinferior wall (5.7 +/- 1.7 dB, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Cyclic variation of ultrasound backscatter in normal myocardium is view dependent: clinical studies with a real-time backscatter imaging system

Real-time ultrasound backscatter imaging is a new method of evaluating relative integrated backscatter in a clinically applicable manner. The potential clinical utility of real-time backscatter imaging of diseased tissue depends on recognition of normal variations in cyclic backscatter when measured from different echocardiographic image orientations. The view dependence of cyclic backscatter variation was studied in normal human volunteers. In twenty normal male subjects (mean age 28 +/- 5 years) cyclic variation in integrated backscatter (diastolic minus systolic backscatter) was assessed in multiple left ventricular regions with four standard two-dimensional echocardiographic views (parasternal long-axis and short-axis views, and apical two-chamber and four-chamber views). M-mode backscatter imaging was performed from the standard parasternal long-axis view. Cyclic variation in backscatter was present in the septum only when imaged from the parasternal long-axis view (2.7 +/- 3.1 [standard deviation] decibels [dB], p less than 0.01 for diastole versus systole). The posterior wall of the left ventricle demonstrated cyclic variation of integrated backscatter when imaged from both the parasternal long-axis (4.6 +/- 1.6 dB, p less than 0.01) and short-axis views (2.8 +/- 2.2 dB, p less than 0.01). Cyclic variation in integrated backscatter was not demonstrated in inferoseptal, septal, or lateral wall regions when imaged from the parasternal short-axis view. The apical views did not demonstrate cyclic variation in integrated backscatter in any of the segments studied.(ABSTRACT TRUNCATED AT 250 WORDS)

A new method of bile duct cannulation allowing bile collection and re-infusion in the conscious rat

A technique is described for collection of bile from the surgically-prepared, conscious rat after a postoperative recovery period of 7 days. This model can also be used to study enterohepatic recirculation.

[Investigations on the oil content and saturation value of the oil of flax mutants and their correlation with some other plant characters]

An analysis of the oil content and the refractive index (as a measure of the saturation value of the oil) was carried out during 1961-1964 in a collection of about 700 mutants, derived by X-irradiation from the two stocks no. 6 and no. 36.The average refractive index of the oil was highest under the cool and rainy conditions of 1961, lowest in the warm and dry year 1963. The maximum differences in the mean refractive index of the collections between 1961 and 1963 amount to an iodine number of 6 (mutants of stock no. 6) or 5 (mutants of stock no. 36) resp.The variability of both characters mentioned was significantly increased in the two mutant stocks. The average oil content showed, on the other hand, a decrease of about 1%. The degree of unsaturation of the oil is higher in the mutants derived from no. 6, and lower in the mutants derived from no. 36 when compared with the untreated material. In the present investigation no (no. 36) or negative correlation (no. 6) was found for the characters of oil content and refractive index.Subgrouping of such characters as plant height, seed coat color, flower color, etc. lead to more or less considerable differences in oil content and refractive index. It may be pointed out that mutants with yellow seed coat color are always characterized by a high oil content and a high refractive index.