Thirty percent of older adults report depressive symptoms at primary care visits; however, many more may go undetected. Primary care physicians rarely have the time to adequately assess and treat depression or other mental health problems, and referrals to mental health providers are atypical. Although there are many constraints to primary care physicians being able to adequately detect and treat mental health problems, the surgeon general identifies primary care as a pivotal point of intervention for older adult mental health.
In response to a surgeon general report, several models of integrated care have been developed and tested. The commonality of these intervention models includes bringing together a patient’s entire health care team to collaborate with one another in an effort to effectively diagnose and treat mental health problems. Outcomes have been favorable, with reduced severity of depression, greater satisfaction with care, less mental health care stigma, and lower mortality rates among patients who participated in the integrated care models compared to those patients without such intervention. These integrated care models also had in common the approach of having the health care team communicate in a single face-to-face setting. Although this approach demonstrates effectiveness, it prevents disparately located health care teams from participating. To remedy this gap, researchers atRushUniversityrecently developed and tested a similar integrated care model, but with the addition of electronic networking to allow health care team members located at different facilities the ability to collaborate across their multiple settings.
The Bridging Resources of an Interdisciplinary Geriatric Health Team via Electronic Networking (BRIGHTEN) program integrates the primary care collaboration concepts for geriatric mental health from previous integrated care models with the virtual team communication process developed in the Virtual Integrated Practice (VIP) project to bridge resources of a disparately located interdisciplinary health care team using technology. VIP developed communication protocols via e-mail, phone, and fax to maximize collaboration between primary care providers and community providers who shared patients. BRIGHTEN utilizes VIP communication protocols to allow teams of geriatric specialty professionals to efficiently and effectively make care recommendations and treat older adults without requiring in-person communications.
This study was conducted over four years and included a sample of 150 older adult patients (age 60 and older) from nine academic medical center clinics and two community-based clinics who screened positive for symptoms of depression and anxiety. The primary care physicians of each of these participants became a member of the BRIGHTEN virtual health care team, which included representatives from psychology, psychiatry, social work, physical therapy, occupational therapy, dietetics, chaplain, and pharmacy.
The BRIGHTEN program was evaluated using the RE-AIM framework. RE-AIM has been used to plan health promotion programs, evaluate success, and improve chances of programs working in real-world situations. The model addresses Reach, Efficacy, Adoption, Implementation, and Maintenance. The Geriatric Depression Scale (GDS-15) and the Short Form-12 were used to assess depression and general mental health. Results indicate that the BRIGHTEN Program’s Interdisciplinary approach is promising in treating older adult depression and general mental health. From baseline to six months, significant improvements were found in depression symptoms and general mental health. However, several challenges regarding implementation surfaced. For example, fidelity to the protocol was not consistent across sites. The primary barrier to protocol fidelity was limited time for screening. Additional barriers included limited investment by staff in assessment of mental health issues and staff fears of being unprepared to manage mental health issues. These barriers did not affect outcomes of enrolled participants but may have limited the number of older adults screened in some clinics. Participant-level challenges included difficulty in diminishing mental health stigma and concerns about the cost of mental health services. Solutions require: 1) understanding that building relationships between physicians, nurses, administrative staff, and medical technicians is crucial for maximizing effective participation, 2) encouraging physicians to be less reticent about discussing mental health issues with their patients, and 3) assigning mental health professionals in training to provide services to patients unable to afford mental health services due to a lack of insurance.
