Training in the Assessment of Depression
Training Home Health Care Nurses to More Effectively Identify Depression and Refer Cases for Treatment
Background & Goal
Depression in the home care setting is prevalent, often undetected and inadequately treated. Research has established that many home care nurses believe they are not adequately prepared to screen for depression, particularly among older patients. Failure to detect and adequately treat depression is associated with increased risk for nursing home admission, morbidity, and risk of suicide and mortality from other causes. Medical costs for depressed older adults are estimated to be 50% higher than for non-depressed elderly, including for home care recipients.
The Training in the Assessment of Depression assures that home health care nurses working with patients in their homes better identify symptoms of depression and direct patients to further evaluation.
TRIAD is a training program for the approximately 120,000 home care nurses providing skilled nursing for more than 1 million older adults yearly in the United States. TRIAD helps nurses, as well as social workers, physical therapists, speech therapists, and occupational therapists working in the home health care service sector, identify clinically meaningful depression symptoms and refer suspected cases. TRIAD is a two-prong intervention designed to (1) improve knowledge, attitudes, skills and motivation to detect geriatric depression and to refer suspected cases for further evaluation; and (2) modify, if not already in place, a home health care agency’s procedures to support depression detection and referral procedures.
Even when depression screening with standardized words are used (i.e., PHQ-2, GDS-15) nurses benefit from TRIAD given the medical complex status of these patients and nurse-identified need for more training. Further, patients often need a great deal of encouragement and support to follow through with appointments for mental issues that they may not feel are essential. The core educational TRIAD program consists of two sessions, one month apart, totaling 4 ½ hours. It is designed to be delivered by a nurse, psychologist, social worker, or medical doctor knowledgeable about geriatric depression and barriers to recognition and referral in the home care setting. A web-based version of TRIAD, including how to assess for suicidal ideation, and the Depression Tool Kit are now available.
TRIAD was developed by Brown, Martha L. Bruce, PhD, MPH, and their colleagues at the Weill Medical College of Cornell University following a series of studies that established depression in older adult home health care patients is prevalent and often remains undetected and inadequately untreated.
Evidence of Success
- Clinical Outcomes: In 2007 a randomized trial among 53 home care nurses, the nurses who received the TRIAD were 2.5 times as likely to correctly identify depressed patients and refer them for further evaluation, following agency protocols, with the referrals leading to better clinical outcomes. There was no effect on unnecessary referrals for research-confirmed patients without depression (i.e., the intervention did not promote false-positive referrals).
- Financial Outcomes: Based on a 2009 study of health care costs associated with depression in medically ill fee-for-service Medicare patients, national implementation of TRIAD – by at least doubling the number of depressive episodes recognized, referred, and treated – could save $10,000 per patient, by reducing outpatient and long-term care costs.