Evaluation of Geriatric Home HealthcareDepression Assessment and Care

Management: Are OASIS-C DepressionRequirements Enough?

Dianne V. Liebel, R.N., Ph.D., Bruce Friedman, Ph.D., M.P.H., Yeates Conwell, M.D.,Bethel Ann Powers, R.N., Ph.D.

Received NovemRochester, NY; aDentistry, RocheNursing, 601 Elm

� 2014 Amehttp://dx.d

Am J Geriatr Ps

Objective: Research is scarce on how depression is identified and treated among

Medicare home healthcare (HHC) patients age 65þ with disability. The Centers for

Medicare & Medicaid Services (CMS) recently incorporated depression screening into

the OASIS-C HHC assessment. Our study objectives were to evaluate and characterize

depression care management (DCM) in an HHC agency after CMS increased its

depression requirements and to determine if there was an association of DCM with

disability (activities of daily living [ADLs]) outcomes. Methods: The authors con-

ducted a retrospective chart review of 100 new Medicare HHC admissions patients

age 65þ (mean age: 81.7) who screened positive for depression and had disability

and multimorbidity. Clinical and administrative records were examined and

descriptive analyses used. Multivariate regression analyses investigated the associa-

tion of six DCM components with ADLs improvement. Results: Depression was

recognized in care plans of 60% of patients. Documentation of only one nurse care

management activity, antidepressant use, indicated the use of evidence-based stan-

dards of depression assessment and DCM. Depression measures were not adminis-

tered at discharge, recertification, or transfer. Forty percent of patients had a formal

depression diagnosis by the referring physician in the chart, and 65% were receiving

an antidepressant. Having a depression care plan and depression medication were

significantly associated with a large ADLs improvement. Conclusion: Despite the

association of depression care plans with patient disability improvement, inadequate

compliance to evidence-based DCM was found. Medicare and HHC agencies must

ensure compliance to DCM, including follow-up depression assessment for patients

with positive screens. (Am J Geriatr Psychiatry 2014; -:-e-)

Key Words: Home healthcare, disability, nurse depression care management

ber 13, 2013; revised June 19, 2014; accepted June 20, 2014. From the University of Rochester School of Nursing (DVL, BAP),nd the Departments of Public Health Sciences and Psychiatry (BF, YC), University of Rochester School of Medicine andster, NY. Send correspondence and reprint requests to Dianne V. Liebel, R.N., Ph.D., University of Rochester School ofwood Ave., Rochester, NY 14526. e-mail: Dianne_Liebel@urmc.rochester.edurican Association for Geriatric Psychiatryoi.org/10.1016/j.jagp.2014.06.009

ychiatry -:-, - 2014 1

Evaluation of Geriatric HHC Depression Assessment and Care Management

INTRODUCTION

Despite the high prevalence of depression in Medi-care home healthcare (HHC) patients,1e3 MedicareHHC reimbursement and quality assurance evalua-tion continue to emphasize assessment and treatmentof physical health. Because Medicare pays for part-time or intermittent skilled HHC services (i.e., nurse,physical therapist, occupational therapist, speech lan-guage pathologist, and social worker for homeboundpatients and home health aide care as a supportiveservice to skilled care),4,5 patients are rarely referred toHHC specifically for depression care.6 A nationalstudy found that 6.4%ofMedicareHHCpatients had adepression diagnosis, whereas an earlier studyreported a rate as high as 13.5% for a single HHCagency.2Moreover, less than 1%of thediagnosed casesin both studies listed depression as a primary diag-nosis in theHHC record.2,3 Depression in theMedicareHHC population can be very problematic,7,8 resultingin such negative consequences as poor quality of life,9

increased mortality,10 and higher healthcare use andcosts.10,11 Importantly, emerging evidence suggeststhat depression care management (DCM) may bebeneficial for HHC patients.12 HHC nurses are wellpositioned to provide DCM to patients living at home.

Past research has demonstrated that when providedwith educational interventions to assess depression,HHC nurses are able to effectively identify and refergeriatric patients for depression treatment.13,14 How-ever, most evidence supporting the effectiveness ofnurse DCM has been limited primarily to quality ofcare improvements and DCM in hospital andprimary care settings.3 Because the clinical functionsof DCM in primary care are consistent with much ofroutine HHC nursing practice, a small number oftrials have tested primary careebased multifacetedinterventions14,15 adapted for HHC.3 Results fromearly DCM studies were promising (but not withstatistically significant findings for depression out-comes),16,17 thereby generating a number of addi-tional studies testing the effectiveness of interventionsrefined for and adapted to the HHC setting (e.g., Carefor Patients at Home and interprofessional mentalhealth promotion interventions).17,18 Despite prom-ising results from these studies for depression out-comes, depression remains mostly undetected orpoorly treated in HHC patients.13,18

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As far back as the year 2000, surveys of HHCagencies have found that despite the Centers forMedicare & Medicaid Services (CMS) requirementfor HHC nurses to report depressive symptoms, thehistoric physical health emphasis of MedicareHHC persistently continues.3,12 Evidence of this isreflected by the relatively low referrals to socialwork resources, dominance of nonemental healthdiagnoses, low screening of depression, and fewdepression interventions implemented by HHCagencies.12 To address this issue, in 2010 depression-related screening requirements on the federal govern-ment’s Outcome Assessment and Information Set(OASIS) start of care (SOC) assessment instrumentwere significantly increased.4,5 Specifically, the PatientHealth Questionnaire 2 (PHQ-2), a quick and validdepression screen,19,20 was added to the latest versionof OASIS (the OASIS-C)4,5 as a recommended, butoptional, way of assessing depression. Being optional,the nurse may choose to use the PHQ-2 screening toolor a different screening tool for depression assessment.CMS instructs but does not mandate HHC agencies toconduct further depression evaluation or follow-upmonitoring for patients whose scores are positive onthe depression tool (e.g., a PHQ-2 score of 3þ).7,8

Consequently, great heterogeneity has occurredacross HHC agencies regarding depression standardsand protocols for follow-up depression evaluation.3,12

More recently, a new section was added to theOASIS-C, a Plan of Care (POC) synopsis, that inquireswhether there is a physician-ordered depressionintervention (e.g., medication) in the POC.5 TheHHC agency is able to document and plan depressioncare as itwould for any other illness or disease. Answeroptions include “no,” “yes,” or “not applicable” andoffer minimal clinical guidance about how to deliverdepression treatment or management (e.g., suggestinginterventions such as medication or resources/re-ferrals).3,12,22 However, an HHC agency’s focus onmedical illness and disability usually drives the treat-ment plan.4e6 Thus, the level of psychological distressoften present in older HHC patients with chronicillness has the potential to be minimized or attributedto medical illness.20 Furthermore, depression is rarelyconsidered a condition that warrants HHC interven-tion. Therefore, it is often undertreated in HHC.2,8,18

Given poor clinical outcomes and the availability ofeffective treatments for older HHC patients with

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Liebel et al.

depression,22,23 there is an important opportunity forHHC nurses to do more.3,22 HHC nurses can play animportant role in reducing patients’ morbidity, utili-zation of care, and costs12,22 through training in howto apply evidence-based practices that currently existbut are not often part of routine HHC practice.3 Theseinclude assessing the severity and course of depres-sion, coordinating depression treatment with physicaland mental health providers, managing antidepres-sant medication, and assisting patients with directcare while helping them to become active in their owntreatment.3,8,18 Nevertheless, in many HHC agenciesthis type of nurse training about depression, as well asdepression standards, is nonexistent.3

Because the lack of strong requirements byOASIS-Cleaves depression screening, monitoring and treat-ment initiatives largely to the voluntary action ofagencies,4,5 it is essential to evaluate how the recentchanges in the OASIS-C have been used by HHCagencies. The first purpose of this study was,therefore, to assess the extent to which activities byHHC nurses in oneMedicareHHC agency in an urbansetting in upstate New York reflects DCM required byOASIS as documented in the HHC chart when a pa-tient screens positive for depression. Furthermore,CMS has mandated attention to physical outcomes forhomebound patients receiving HHC, with physicaloutcomes being operationalized as activities of dailyliving (ADLs) and instrumental activities of dailyliving (IADLs) disability. Together, the focus onphysical health and ADLs underscore the importanceand clinical meaningfulness of demonstrating howDCM impacts disability outcomes12,23 Therefore, thesecond purpose of this study was to determine ifcompliance with DCM standards by HHC nursesimproved disability outcomes among HHC patientswith a positive depression screen.

METHODS

Design

We conducted a retrospective chart reviewdesigned to characterize and evaluate DCM.

Sample

We extracted a random sample of 100 HHC chartsfrom a not-for-profit, Medicare-certified HHC agency,

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one of the largest HHC agencies in upstate New York(conducts 600,000þ visits/11,000 urban/suburbanpatients annually) that employs one full-time psy-chiatric nurse. According to the Home Health CareConsumer Assessment of Healthcare Providers andSystems Survey24,25 on the CMS Home HealthCompare website, this agency ranked in the 57thpercentile nationally for measures of quality care andin the 34th percentile nationally for measures of pa-tient experience with HHC. The source of the samplewas charts of older (65þ years old) HHC patientswho had received an episode of HHC within an18-month window of time in a single Medicare HHCagency. Charts of patients admitted since the initia-tion of OASIS-C (January 2010) were extracted fromthe agency’s electronic database, using a computer-ized eligibility checklist. Inclusion criteria were asfollows: (1) Medicare beneficiary, (2) age 65 years orolder, (3) new admission, (4) positive PHQ-2 (scorerange 0e6; score 3þ represents a positive screen fordepression), (5) disability (dependence in 1þ ADLand 1þ IADL), (6) multimorbidity (3þ chronic ill-nesses), and (7) HHC discharge date. These criteriawere used to limit charts examined to those ofhomebound persons who had depression, disability,and chronic illness, in contrast to those of patientswho might be receiving HHC due to subacute illness,postsurgery, and/or injuries.

Procedure

Patient charts were reviewed to identify the numberof HHC visits, duration of each episode of care,primary diagnoses, secondary diagnoses and comor-bidities, disability scores, and components of depres-sion management. A record abstraction review toolwas constructed that included a checklist of 52 itemsin three categories: (1) physical health nursing ass-essments (sociodemographics, ADL/IADL disability,chronic illness, health behaviors [specific OASIS-Cquestions]) were performed to prevent enrolling per-sons who might be homebound for a different reasonother than chronic medical illness/disability; (2) DCMactivities documented in patient charts (depressiondetection [positive PHQ-2 and use of follow-updepression evaluation in charts using a morecomprehensive depression instrument such as thePHQ-9], referrals [yes/no referrals to mental healthproviders], assessment [yes/no OASIS-C depression

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Evaluation of Geriatric HHC Depression Assessment and Care Management

items; yes/no nurse depression documentation in theinterdisciplinary note section of the record], andplanning [yes/no depression care plan]); and (3) HHCresource use (e.g., number/type of visits, episodeduration [number of days between the SOC anddischarge date]). These categories were used to iden-tify data considered critical for the assessment ofdepression and disability based on our previousresearch26 and literature review.27 To put these data incontext, although many DCM indicators used in thisstudy are available in the charts of most agencies,others (perhaps the PHQ-9) may be unique to theagency being studied. Chart review data were enteredinto a de-identified electronic database twice for ac-curacy. The research protocol was approved by theUniversity of Rochester Research Subjects ReviewBoard.

Measures

Data were obtained from several sources. First,data on disability, depression, medical conditions,and other patient characteristics (e.g., demographics,health status, lifestyle, and health insurance) wereobtained from the OASIS-C, which was administeredby nurses at the start of each HHC episode, every 60days thereafter, and at discharge from homecare.Second, data were abstracted from the progress notesbased on expert nurse rater judgment regardingpresence of documentation indicating depressiondetection, depression referrals, and depression/disability care planning and management as well asuse/referral of healthcare services. Third, measuresfrom the OASIS-C and the agency’s prospectivepayment database were used to track dischargelocation, HHC episode duration, and the number ofnursing, physical therapist, social work, and mentalhealth nurse visits. Fourth, length of HHC stay wasobtained from agency administrative records. Fifth,data were abstracted from the OASIS-C about anti-depressant use (yes/no antidepressant; antidepres-sant name; and yes/no more than one).

Disability Outcomes. OASIS-C disability outcomemeasures for difficulty and dependence in each ofnine individual ADLs (grooming, bathing, upperbody dressing, lower body dressing, eating, toiletingtransfer, toileting hygiene, transferring, and ambula-tion) were routinely collected at the beginning andend of the HHC episode. In addition, data were

4

collected on difficulty or dependence in performingtwo IADLs: telephone use and planning and pre-paring light meals (the only OASIS IADLs).

For the ADL index score, the responses to eachitem were collapsed into three categories (0: inde-pendent, 1: some difficulty, and 2: dependent). Thetotal ADL index score then was calculated by addingall nine items. The possible range was from 0,completely independent, to 18, completely depen-dent. Because improvement in functional status wascalculated from OASIS-C data at the beginning(baseline) and end (follow-up) of the HHC episode,cases that were not discharged from HHC (patientswho were hospitalized, died, or refused care) werenot included in the analytic sample for the twodisability outcomes: amount of ADL change andlarge ADL improvement (yes, no). Thus, the analyticsample for the multivariate models was limited to the71 cases with baseline and follow-up OASIS-C data.

For change to the ADL index score, the change scorewas calculated by subtracting the baseline ADL indexscore from the discharge ADL index score. A zeroindicated no change in ADL score. A negative scoreindicated the patient exhibited worsening disability.

Chronic Illness/Diagnosis. OASIS-C data elementswere used for the primary diagnosis and any sec-ondary diagnoses or comorbid illnesses/conditions.The OASIS primary diagnoses are defined by CMS asrelevant medical conditions most related to the cur-rent POC but that must also be related to the skilledservices rendered by HHC agencies. Each patient’sprimary diagnoses were abstracted using the Inter-national Classification of Diseases, Ninth Revision, Clin-ical Modification (ICD-9-CM) codes and collapsed into13 categories (e.g., cardiac, neurologic disease). Sec-ondary OASIS diagnoses as defined by CMS reflectconditions that coexisted at the time the POC wasestablished or that developed subsequently aftertreatment began.

Nurse DCM Activities

The six care management activities considered tobe key components of best practice care for nurseDCM28,29 were extracted from the chart:

1. Depression diagnosis: The primary or secondarydepression diagnosis listed by the HHC nurse onthe OASIS-C. HHC nurses identify a depressiondiagnosis and confirm this with the patient’s

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Liebel et al.

physician. These diagnoses could have beenmodified by the HHC nurse during the episodeof care when there was a change in a patient’sdepression status that subsequently was nottracked by the HHC agency (via ICD-9-CMcodes for identified depression, e.g., majordepression single episode; major depressionrecurrent episode).

2. Depression medication (antidepressants): Whetherthere was an antidepressant prescribed duringthe HHC episode, the name of the antidepres-sant, evidence of more than one antidepressantprescribed, whether each antidepressant wasinitiated at SOC, and whether each antidepres-sant was initiated after SOC.

3. Depression care planning and follow-up screening:Whether any depression care planning wasperformed and documented by a nurse, nursespecialist, therapist, or social worker (docu-mented as depression care plan, per agencyprotocol and use of a depression screening in-strument to follow-up the initial screen).

4. Nurse discussion of depression: Whether there wasdocumentation about discussion of depressioncare (located in nurses’ interdisciplinary progressnotes, per agency protocol) and documentation ofthe depression care plan used during HHC visits.

5. Number of nurse visits: The number of HHCnursing visits that occurred during the HHCepisode (between SOC and discharge date).

6. Number of physical therapy visits: The number ofHHC physical therapy visits that occurred duringthe HHC episode (from SOC to discharge date).

Data Analysis

The analyses were done in two stages. The firststage consisted of descriptive analyses of data fromall 100 charts to characterize the sample and the DCMactivities nurses documented. The second stageinvolved regression analyses of the subset of 71subjects who had data at the beginning and end oftheir episode of care.

Evidence of DCM. Descriptive statistics werecomputed for all continuous variables. Frequencydistributions and percentages were calculated forcategorical variables.

DCM and Disability Outcomes. After calculatinginferential statistical tests, we conducted both un-adjusted (raw) correlations and logistic regressionanalyses to examine whether each of the six DCM

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activities (depression diagnosis, depression care plan,depressionmedication, nurse discussion of depressionwith patient, number of nurse home visits, and num-ber of physical therapy home visits) was associatedwith a large ADL improvement (change scores �þ5).In addition to the baseline value of the ADL index, thefollowing patient factors were included in all multi-variate analyses: age, male gender, nonwhite race,overall health status, risk factor score (summed scoreof presence of obesity, smoking, and drug/alcoholuse), cognitive functioning (choice of four categoriesranging from oriented to needs considerable assis-tance), and number of days of the HHC episode (SOCto discharge date). Huber30 and White31 robust stan-dard errors were calculated for the regression ana-lyses. The statistical software SPSS 15.0 (SPSS Inc.,Chicago, IL) and Stata version 12 (StataCorp LP, Col-lege Station, TX) were used for the data analysis.

RESULTS

Sociodemographic Characteristics

The study sample consisted of 100 Medicare HHCpatients with both depression and disability from oneMedicare HHC agency. The sample was 55% womenwith a mean age of 81.7 years (Table 1). Seventy-onepatients had data at the start and end of the HHCepisode. Data were not available for 29 patients atepisode end due to attrition, including death.

Chronic Illnesses at Admission

Patients had, on average, 4.5 chronic illnesses. Themost frequently selected medical diagnoses identifiedby nurses were heart disease, pulmonary disease,and arthritis. Mental disorders were not reported inthe top five primary diagnoses, but depression,dementia, and anxiety were selected as secondarydiagnoses. Overall, the most frequently indicatedprimary diagnosis by nurses was “need for PT.” Thisdiagnosis was selected when a patient’s treatmentwas primarily directed at rehabilitation (Table 1).

ADLs at Admission

Extracted data from the charts showed that beforethe HHC episode, about one-third of patients wereindependent in self-care, ambulation, or transferring.

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TABLE 1. Characteristics of HHC Patients and HHC PatientsCompleting HHC Episodes Using OASIS-C Data

Characteristic

Patient(N [ 100)

N (%)

Patient(N [ 71)N (%)

SociodemographicsMean age (SD), y 81.68 (7.3) 81.9 (7.6)Age group

66e74 21 (21) 13 (18.3)75e84 41 (41) 24 (33.8)85þ 38 (38) 34 (47.6)

RaceWhite 82 (82) 59 (83.1)African American 14 (14) 3 (4.2)Ethnicity (Hispanic) 4 (4) 9 (12.7)

GenderFemale 45 (45) 40 (56.3)Male 55 (55) 31 (43.7)

Health insuranceMedicare Only 63 (63) 48 (67.6)Medicaid Fee for Service 25 (25) 9 (12.7)Dually eligible 12 (12) 14 (19.7)Other Insurance 0 0

Discharged fromIn-patient rehab hospital 8 (8)Short-term acute skillednursing facility

6 (6) 12 (16.9)

Short stay acute hospital 37 (37) 24 (33.8)Long-term nursing 1 (1)Patient not discharged fromin-patient facility

48 (48) 35 (49.3)

Risk Factors affect currenthealth (% answered yes)

Smoking 12 (12) 7 (9.8)Obesity 24 (246) 17 (23.9.)Alcohol 10 (10) 55 (77.4)Drug 7 (7) 2 (2.8)Any 68 (68) 25 (35.2)

Cognitive functionAlert/oriented 17 (17) 12 (16.9)Requires prompt 48 (48) 31 (43.7)Requires assistance 26 (26) 21 (29.6)Requires considerable assistance 9 (9) 7 (9.9)

Chronic illnesses/diagnosisPrimary diagnosis

Physical therapy 30 (30) 19 (26.8)Congestive heart failure 10 (10) 10 (14.1)Cardiovascular disease 9 (9) 4 (5.6)Pulmonary 7 (7) 6 (8.5)Arthritis 7 (7) 5 (7)Postsurgical care 6 (6) 4 (5.6)Dermatologic 6 (6) 5 (7.0)Injury/fracture 6 (6) 5 (7.0)GI/GU 6 (6) 5 (7.0)Cancer 3 (3) 3 (4.2)Alzheimer and dementia 3 (3) 2 (2.8)Medication use/monitoring 2 (2) 2 (2.8)Neurologic disorders 1 (1) 1 (1.4)

Top 5 comorbid conditionsAbnormality of gait/walkingdifficulty

17 (17) 7 (8.5)

Cardiovascular/CHF 7 (7) 13 (18.3)Arthritis 7 (7) 7 (8.5)

(Continued)

TABLE 1. (Continued)

Characteristic

Patient(N [ 100)

N (%)

Patient(N [ 71)N (%)

Mental Health 5 (5) 5 (7.5)Muscle weakness 2 (2) 5 (7.5)Mean number of chronic illnesses 4.5 (2.3) 4.3 (2.1)

Overall health statusHeighted risk of poor health 13 (13) 9 (12.7)Temporary risk of poor health 49 (49) 36 (50.7)Likely to remain in fragile health 33 (33) 24 (33.8)

Prior conditionsUrinary incontinence 52 (52) 38 (53.5)Indwelling/suprapubic catheter 23 (23) 0Intractable pain 37 (37) 15 (21.1)Impaired decision making 6 (6) 31 (43.7)Disruptive behavior 14 (14) 5 (7.0)Memory loss 41 (41) 9 (12.7)None 12 (12) 31 (43.7)

Notes: GI: gastrointestinal; GU: genitourinary; CHF: congestiveheart failure.

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Evaluation of Geriatric HHC Depression Assessment and Care Management

Additionally, at the beginning of the episode almostall patients had some difficulty with or dependencein three ADLs, bathing, ambulation, and transferring,and one IADL, preparing meals. The mean SOC ADLdependence score was 9.0 (standard deviation [SD]:2.3) on an 18-point scale (Table 2).

Depression Assessment and Care Management

Although depression was recognized by nurses inthe care plans of 60% of patients, there was limited in-formation about the use of clear evidence-based stan-dards of depression assessment and caremanagement,and depression outcome measures were not adminis-tered at discharge, recertification, or transfer. Nursesmade referrals to social workers (28% of patients),psychiatric nurses (15%), and mental health specialists(5%). Forty percent of patients had a depression diag-nosis (ICD-9-CM code) on the OASIS-C. In all cases,this was not a primary diagnosis.

Additional documentation revealed that 65% of 71patients with data at the start and end of the HHCepisode received an antidepressant and 20% of thosepatients received more than one. Forty-seven of 71patients received depression medication during theepisode. Twenty-seven of the 47 patients werereceiving an antidepressant at SOC, whereas theremaining 20 received an antidepressant later in theirepisode of care. Patients’ antidepressant use beforetheir HHC episode was not recorded.

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TABLE 2. Physical and Psychosocial Health Outcomes During HHC Episode for HHC Patients Using OASIS-C Data and N (%) ofSubjects and Mean and SD for Continuous Variables

Physical Health Outcomes

Independent Some Difficulty Dependent

Prior ADL/IADL functioningSelf-care 27 56 17Ambulation 33 57 10Transferring 34 57 9Household tasks 8 44 48

ADL dependenceBathing 0 93 7Ambulation 2 93 5Transferring 6 89 5Grooming 7 86 7Dress upper body 6 88 6Dress lower body 5 83 12Toilet transfer 21 74 5Toilet hygiene 21 72 7Eating 18 72 10

IADL dependencePrepare meals 5 41 53Telephone 46 41 13

Reported Cognitive BehavioralPsychiatric Symptoms at LeastOnce per Week (Yes) N/% Psychosocial Health Outcomes N/%

Memory loss 39 Depression diagnosis 41Impaired decision making 49 Anxiety diagnosis 14Memory loss 1 PHQ-2 depression score 4.5Impaired decision-making 2 Anxiety symptoms (daily) 54Verbal disruption 1 Antidepressant use 65Delusional hallucinations 1 Nurse depression intervention (OASIS) 92

Depression care plan 60

Healthcare Service Use

Visits in the Home Mean (SD) Referrals %

Nursing 10 (1.3) Social worker 28Physical therapy 7.5 (1.2) Physical therapy 86Social work 1.2 (0.4) Psychiatric nurse 5Psychiatric nurse 5 (0.6)

Times Found in Chart % Mean (SD)

Depression management 40 Days in episodeOne episode 39.9 (15.34)

Depression care plan 40 More than one episode 139.2 (110.7)Interdisciplinary note 47 No. of patients

One episode 26 (36.6%)More than one episode 45 (63.4%)

Liebel et al.

Nurses consistently chose the PHQ-2 instrumentfor every assessment of depression and recordedanswers to both PHQ-2 depression questions in thechart (100%). In addition, they documented whendepression care plans (40%) were present. However,nurses did not document consistently in the samelocation in the charts about how depression treat-ment or care management was carried out (e.g., 30%

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provided education about antidepressants). Inaddition, nurses inconsistently documented use ofpsychological or psychoeducational interventions(e.g., 20% mentioned therapeutic communicationand depression education). Overall, there wasmention of depression in only 10% of the dischargesummaries despite the presence of a depressiondiagnosis.

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TABLE 3. Unadjusted (Raw) Spearman Correlation BetweenLarge ADL Improvement and Each of Six HHCComponents (N [ 71)

HHC ComponentSpearman’s r

Correlation Statistic p

Depression care plan 0.257 0.030Depression medication �0.230 0.054Number of nurse visits �0.177 0.139Nurse discussion of depression �0.102 0.397Number of physical therapy visits �0.096 0.425Depression diagnosis 0.007 0.952

Notes: ADL improvement is a dichotomous variable coded as 1(large improvement) or 0 (little or no improvement). Patients withan ADL change ranging between þ5 and þ10 were coded as 1 andthose with an ADL change ranging from �2 to þ4 were coded as 0.

Evaluation of Geriatric HHC Depression Assessment and Care Management

Of the 46 patients with a depression diagnosis onthe OASIS-C, 32 (69.6%) had a depression care plan.Of the 54 patients who did not have a depressiondiagnosis on the OASIS-C, 28 (51.8%) had a depres-sion care plan and 21 patients out of all patients (21%)had a primary diagnosis at discharge that wasdifferent from the primary diagnosis at admission.

HHC Services Use

HHC services used by patients included physicaland occupational therapy (86%), skilled nursing(84%), social worker (24%), and psychiatric nurse(9%). For the entire sample, the mean number ofvisits was 10.8 (SD: 11.1) for nurses, 7.5 (SD: 5.2) forphysical therapists, and 1.2 (SD: 0.4) for socialworkers. The average duration of an HHC episodefor all patients was 65.7 (SD: 72.1) days. Five HHCnurses conducted home visits across 100 patients.

ADL Change During HHC Stay

Of the 71 patients for whom there were data atboth the beginning and end of the HHC episode, only2% experienced ADL decline. The remaining 98%either improved (84.5%) or stayed the same (12.6%).

HHC Components Associated with Large ADLImprovement

Thirty-three patients had a large ADL improvement(change scores ranging betweenþ5 andþ10), whereas38 had a small improvement (26 patientswith a changebetween þ1 and þ4), no change (10 patients), or aworsening (one patientwith�1 and onewith�2)ADLscore. Large ADL change was significantly correlatedwith having a depression care plan (Spearman’s r ¼0.257; p ¼ 0.030) and weakly correlated with use ofdepression medication (Spearman’s r ¼ �0.230; p ¼0.054; N ¼ 71) (Table 3). In the multivariate logisticregression analyses, two HHC features were signifi-cantly associated with a large ADL improvement:having a depression care plan and depression medi-cation. The latter had a negative association (Table 4).

DISCUSSION

Findings from this study suggest that CMS changesintended to improve OASIS had limited impact on

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improving HHC nurses’ implementation of DCMactivities, including recognition of depression,depressionmonitoring and follow-up, patient referralsto mental health providers, and initiation and use of adepression care plan. We discuss findings and sug-gested actions related to each of these in light of currentknowledge as well as the mixed findings about an as-sociationbetweenDCMplansand improveddisability.Based on a summary of these analyses, we concludewith areaswehave identified that canbe improvedandstrengthened so they can be delivered by HHC nursesduring home visits taking place throughout the courseof a patient’s CMS-approved episode of care.

Recognition of Depression

In our study, the PHQ-2 was judged to have suffi-cient accuracy to identify HHC patients at risk fordepression based on its demonstrated high positivepredictive value (PPV) for depression detection andscreening for both aging services clients (PPV: 75% forPHQ-2 score of 3þ; PPV: 95% for PHQ-2 score of5þ)32,33 and HHC patients (PPV: 72% for PHQ-2 scoreof 3þ).34 All patients in this study had a positivedepression screen (a PHQ-2 score of 3þ on OASIS)and an average PHQ-2 score of 4.5 out of 6. However,HHC nurses (using the PHQ-2) identified depression,by calling attention to it in their notes, in only 40% ofthese cases. Considering that prior research amongcommunity-dwelling older persons with high preva-lence of depression found that the PHQ-2 demon-strates good psychometric characteristics for detectinga current major depressive episode, this low rate ofdocumented recognition of patient depression bynurses is troubling.6,35

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TABLE 4. Logistic Regression Model Results for Large ADL Improvement (Dependent Variable) Independent Variable of Interest inSeparate Regression Models

Independent Variable of Interest Odds Ratio Robust Standard Error z p 95% Confidence Interval Pseudo R2 N

Depression care plan 3.89 0.609 2.23 0.026 1.18e12.83 0.237 71Depression diagnosis 0.93 0.533 �0.14 0.893 0.33e2.64 0.182 71Depression medication 0.19 0.747 �2.20 0.028 0.04e0.84 0.250 71Nurse discussion of depression 0.66 0.600 �0.70 0.484 0.20e2.13 0.186 71Number of nurse visits 0.97 0.060 �0.44 0.661 0.87e1.09 0.183 71Number of physical therapy visits 0.92 0.058 �1.36 0.173 0.82e1.03 0.196 71

Notes: Dependent variable ADL improvement is a dichotomous variables coded as 1 (large improvement) and 0 (little or no improvement).Patients with an ADL change ranging between þ5 and þ10 were coded as 1 and those with an ADL change ranging from �2 to þ4 werecoded as 0. Each model controls for baseline ADL score, age, sex, race, overall health status, risk factor score, cognitive functioning, andnumber of Medicare HHC episode days.

Liebel et al.

Depression frequently was either not documentedby nurses or documented but not identified on thePHQ-2. Chart reviewebased observations, alongwith prior research findings, suggest key reasonswhy HHC nurses may not identify depression accu-rately using the PHQ-2 screening tool. First, regula-tory and financial priorities of HHC are targeted topatients’ physical health instead of chronic illnessesand mental health issues.3,4,13,18 Thus, nurses mayhave been more likely to view patients’ depressivesymptoms as part of an underlying physical problem(e.g., pain associated with a chronic condition insteadof depressive symptoms).18,26,32 Second, becausenurses are required to ask the PHQ-2 questions at thestart of an episode of care, nurses documented thatthey are often reluctant to ask these questions beforethey have had time to establish therapeutic nurseepatient relationships. Moreover, there is abundantevidence that these relationships need time for thedevelopment of trust, an essential ingredient for pa-tient comfort in discussing depressive symp-toms.3,36,37 Because of perceived patient reluctance,nurses often reworded the questions or only askedone of the two questions. Thus, the PHQ-2 depressionscreen results may not be consistently accurate orreliable.

In our prior research, when HHC nurses wereasked about how to handle depressive issues, theyexpressed a strong desire to gain additional depres-sion training (e.g., screening scales, care managementprotocols for elderly persons).7,26,36 This type ofeducation and training has been shown to enablenurses to ask the two PHQ-2 questions with ease andconfidence.7,32,33 Additionally, the training enablednurses to not only learn the value of asking the PHQ-2 questions but also how to take effective action on

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positive results and create a treatment and manage-ment plan. Importantly, emerging evidence from thischart review and prior research reveal that this typeof training also needs to be enhanced with teachingnurses how to use interpersonal skills to develop andsustain productive therapeutic realtionships.18,36,37

Depression Monitoring and Follow-Up

In this study there was no apparent standardmethod for HHC patients’ physicians to be notifiedabout a positive depression screen. According to theagency, the decision to notify or not was based onnurse judgment. Thus, when patient depression wasrecognized by nurses, information pertaining tomonitoring and follow-up was often inconsistentlydocumented in the chart (i.e., the documentation wasfound in different places) or was absent from thecharts. Moreover, there was no evidence of a stan-dard or established protocols in the charts withguidelines about how and when to notify physi-cians/healthcare providers directly about patients’depressive symptoms.3,10 Also, there was no unifor-mity in depression documentation or follow-up andmonitoring of depression between and within cases(e.g., substantive and narrative differences in how thesame nurse documented information about depres-sion for multiple different patients).

Despite sufficient evidence that indicates the PHQ-2 should only be considered a “first step” indepression screening, there was little evidence in thecharts of depression follow-up screening after apositive PHQ-2.6,38 Systematic follow-up is neededfor any positive screen, including more in-depthevaluation to determine whether a person meets thefull criteria for a depressive disorder or whether

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Evaluation of Geriatric HHC Depression Assessment and Care Management

referral to a physician for a full diagnostic assessmentis indicated.6,21,38 Based on the findings of this studyand prior research,3,26,36 we suggest that CMSreconsider current requirements for depressionscreening, expanding required time points to includenot only the SOC but also at resumption of care andall transition points in the HHC episode (e.g.,discharge).37 These time points provide prime op-portunities to reassess depression and incorporatedepression treatment into nurse care management.

Patient Referrals to Mental Health Providers

Evidence in the charts showed nurses making pa-tient referrals to primary care physicians rather thanmental health providers when there were depressivesymptoms or suicidal thoughts (although when therewas an actual depression diagnosis, nurses weremore likely to make referrals to mental health pro-viders). The nurses documented patient referralsconsistently and with uniformity in the charts.However, after the patient referrals were made, therewas a paucity of documented interprofessionalcommunication or interaction with these mentalhealth providers. Nurse documentation about con-versations with or telephone calls to these providersprimarily was associated with medication issues (e.g.,change in antidepressant therapy) or arranging re-sources so homebound patients could attend visitswith mental health providers.

There was also a low rate of nurse referrals tomental health providers within the agency, such associal workers or psychiatric nurses. Moreover, whenpatient referrals were made to social workers bynurses, the documentation by both was focused oncounseling patients regarding transitions to othersettings (e.g., nursing homes) rather than patients’depressive symptoms. Psychiatric nurses’ notesregarding patients’ mental states primarily concen-trated on care delivery for those with severe mentalillnesses (e.g., schizophrenia). The charts revealedthat nurses did not believe it necessary to call thepsychiatric nurse for a patient’s depressive symp-toms or that the psychiatric nurse was unavailablebecause of a burgeoning caseload. This lack ofinterdisciplinary communication overall is endemicto HHC because of professional isolation connectedwith visiting patients in their own homes.13,24 Therewas evidence of an effort by the participating HHC

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agency to improve interdisciplinary and interprofes-sional communication by initiation of an interdisci-plinary communication note (i.e., open text box in thechart). However, this interdisciplinary note seemedto generate little improvement, because of theabsence of guidelines in the chart for its use and staffuncertainty about how and when to use it.

This state of affairs is troubling because mountingevidence shows that effective DCM and treatmentrequires a higher level of interprofessional commu-nication and referrals to mental health providers.3,7,36

It has been found that nurses who receive tailoredDCM training are much more likely to make timelyand accurate referrals to mental health providers.7

Moreover, there is evidence that both socialworkers and nurses can be effective in deliveringdepression interventions to medically ill geriatricHHC patients.38 Thus, agencies need to providetraining on how to circumnavigate known barriers tomaking appropriate patient care referrals.

Initiation and Use of a Depression Care Plan

Reportedly, nurses were not trained to know howto use depression care plans to effectively manageand treat depressive symptoms (e.g., how to writebehavioral goals). Evidence-based depression careplans are considered the best practice protocol fordepression assessment and management.39e41 How-ever, CMS does not mandate that depression careplans be implemented in HHC, despite their provenbenefit.4,9,12 Physicians with HHC patients are onlyrequired to authorize orders for an overall careplan that includes orders for clinical treatments (e.g.,services such as dressing changes or medicationssuch as antidepressants) for which HHC nursesprovide in-home patient care.4,5 However, HHCnurses can also formulate care plans to coordinatenurse activities concurrently with physician orderssuch as targeted disease care plans (e.g., heart failure,depression) or treatment care plans (e.g., preventingpressure ulcers) for which there are a number ofexisting protocols.

In this study, despite having a depression diag-nosis on the OASIS-C, only two-thirds of patients hada nurse-initiated depression care plan. This mostlikely occurred because the participating agencylacked standardized protocols for managing orevaluating nurse-initiated depression care plans for

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Liebel et al.

patients with depression or for patients withdepression and concomitant disability.12,36,42,43 Inaddition, nurses were not trained on how to usedepression care plans to the fullest extent in effec-tively managing and treating depressive symptoms(e.g., how to write behavioral goals). Consequently,depression care plans developed by the HHC nursesin the participating agency included enhancement ofphysical function (e.g., structured exercise or referralsfor physical/occupational therapies)2,27,28 but oftenwere lacking in interventions to maximize patientautonomy/personal control/self-efficacy (e.g., activepatient participation in creating daily schedules andgoal setting). Thus, there is a need for policies at theagency level for depression care plans to be standardpractice for HHC. These care plans need to becomprehensive and more directive than a simple listof nurse activities.

Association between DCM Plans and ImprovedDisability

Our inquiry produced mixed findings regarding arelationship between nurse-initiated DCM plans andimproved disability outcomes among these identifiedvulnerable HHC patients with positive depressionscreens. Consideration of this is important, in view ofthe CMS emphasis on physical disability deficits andchronic illness as the criteria to use in assessing pa-tient eligibility for HHC referrals.

On the one hand, use of a depression care plan byHHC nurses was promisingly associated withimproved disability outcomes. However, many pa-tients in this study with a depression diagnosis on theOASIS-C did not have a depression care plan. Thisfinding reinforces the call by researchers, clinicians,and policymakers to have CMS mandate depressioncare plans as a part of the POC for Medicare HHCpatients with a depression diagnosis on the OASIS-C.3,18,37,41 The success of depression care plans couldbe further enhanced by inclusion of nurse trainingand support in evidence-based DCM activities, whichhave been found to be beneficial in prior nurse homevisiting trials.15e17

On the other hand, disability worsened for HHCpatients who received antidepressant therapy both atSOC and when antidepressants were initiated duringhome visits. A likely interpretation for this counter-intuitive finding is that when people with mood

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disturbances also have severe and debilitating med-ical illnesses, they are more likely to be prescribedantidepressants but less likely to respond to them.Thus, it is important for HHC nurses to be aware thatalthough older persons are receiving antidepressants,they may remain persistently depressed.42 Moreover,nurses need to check patients’ medication lists to seewhether they may be using antidepressants for dis-orders other than depression (e.g., insomnia, fibro-myalgia) or for the treatment of depression without adepression diagnosis.42,43 Finally, it is important fornurses to consider that older depressed HHC patientswith more functionally disabling conditions who arereceiving antidepressants may be less likely toimprove, more likely to have progressively deterio-rating conditions, and more likely to have poorprognosis mood disorders. Thus, referral to a mentalhealth provider or development of a specializedtreatment plan may be needed. We interpret theabove findings in light of the limitations (see below)and potential for other interpretations (e.g., therewere no available data on depression severity).

Limitations

The present study has several limitations. First, itwas conducted in a single large, urban, not-for-profitHHC agency. Therefore, study results may not begeneralizable to rural or suburban areas or other ur-ban agencies. Second, patient outcome measures didnot report demonstrated psychometric properties(validity), thereby limiting effectiveness of the mea-sures. Third, the results of the correlations andregression analyses apply only to patients with bothadmission and discharge OASIS-C forms and not topatients who died, transitioned to other care settings,or were rehospitalized. Fourth, the point at whichantidepressant medications were discontinued orchanged was not documented in the HHC charts norwere the antidepressant doses and changes in doseand depression diagnosis. Fifth, the study was aretrospective chart review and, therefore, dependenton the accuracy of the medical record.

Conclusions

Overall, our results suggest some limited benefitfrom the recent depression changes introduced inOASIS-C, but additional HHC strategies are needed.Despite the ability to screen for depression with the

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Evaluation of Geriatric HHC Depression Assessment and Care Management

PHQ-2, it appears that HHC patients in this studycontinued to have their depression undermanaged.Additional changes are recommended to improvedepression care within the current HHC system,including mandated follow-up depression assess-ment that may lead to treatment and ongoing man-agement for patients who have a positive depressionscreen. Further research is needed to determinewhether providing DCM has the potential to increasethe effectiveness of HHC treatments to prevent orlessen disability worsening and improve quality oflife. HHC practice that includes DCM may help

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improve the debilitating outcomes of depressionand may also positively impact treatment complianceand clinical outcomes of depressed patients withconcomitant disability.

The authors are sincerely grateful for the participationof the home healthcare agency and nurses who made thisstudy possible.

This work was supported by a Faculty ResearchSupport Grant from the University of Rochester School ofNursing, Center for Research and Evidence-BasedPractice.

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