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Project ADAPT: A Program to Assess Depression and Provide Proactive Treatment in Rural Areas

Correspondence: Address correspondence to Marilyn Luptak, Assistant Professor, University of Utah College of Social Work, 395 South 1500 East, Room 101, Salt Lake City, UT 84112. E-mail: Marilyn.Luptak{at}socwk.utah.edu

	Abstract

TOP Abstract Background The ADAPT Model Selected Outcomes Discussion and Implications References

 
Purpose: We describe and evaluate a project designed to pilot test an evidence-based clinical intervention for assessing and treating depression in older adults in rural primary care clinics. Project ADAPT—Assuring Depression Assessment and Proactive Treatment—utilized existing primary care resources to overcome barriers to sustainability experienced by similar projects. Design and Methods: This multifaceted intervention, which was structured after the successful IMPACT (Improving Mood/Promoting Access to Collaborative Treatment) research intervention, used on-site geriatric depression specialists, clinic staff training, team collaboration, and depression practice guidelines to improve depression care for rural elders. IMPACT screening and assessment instruments and treatment protocols were modified for use by less highly trained staff already employed by the rural primary care clinics. Patient and provider depression educational materials and depression screening and monitoring protocols were provided by means of regional training sessions and phone contact. Evaluation data were collected by mail and phone surveys. Results: Although Project ADAPT materials and training were initially developed for providers in rural primary care clinics, most participants came from long-term-care facilities, hospitals, home care, and public health and social service agencies. Forty-four sites sent 56 staff to Project ADAPT regional trainings, but many did not participate after the initial training. Participants who did continue reported that training improved geriatric depression screening and communication with the primary provider. Implications: Outcomes suggest that provider, patient, and system issues have to be addressed differently in rural areas to improve geriatric depression treatment in primary care settings.

Key Words: Collaborative care • Depression • Mental health • Primary care clinics • Rural health care settings

The recently completed National Comorbidity Survey Replication found that, although real progress has been made in getting people to acknowledge depressive symptoms and seek treatment, primary care physicians have not been as adept as they should be at recognizing and treating depression (Wang et al., 2005). Older adults are especially vulnerable to having their depression overlooked because they generally receive their health care from these primary care providers, who, according to a major Institute of Mental Health report, do not provide adequate assessment and treatment of depression for this age group (Institute of Medicine, 2005).

The recognition and treatment of depression in older persons living in rural areas is made even more difficult because of the lack of professionals trained to assess and treat depression, the lack of mental health resources, and the stigma associated with depression, which prevents some older adults from talking to their doctor about depressive symptoms. The most common mental health problems treated by rural primary care practitioners are depression, anxiety and panic disorders, and dementia. A 1999 survey of rural primary care providers found that most thought 10% of their patients' conditions were primarily mental health (Geller, 1999). In Minnesota, the ratio of primary care physicians is lower in rural areas than in urban areas (70/100,000 vs 120/100,000); this is also true for psychiatrists (4.5/100,000 vs 12.3/100,000; see the Office of Rural Health & Primary Care, 2005).

Many published studies that aimed at reducing the gap between evidence and practice have seen mixed results. Unfortunately, few of these projects attempted to translate the evidence about geriatric depression assessment and treatment into rural primary care practice settings. Two recent multisite, randomized, controlled trials, that is, PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial; Bruce et al., 2004) and IMPACT (Improving Mood/Promoting Access to Collaborative Treatment; Unützer et al., 2002), demonstrated that geriatric depression could be successfully identified and subsequently treated in primary care settings with an intensive, multifaceted, collaborative care approach. However, it is unknown if these models can be modified and adapted to the rural setting with similar success.

	Background

TOP Abstract Background The ADAPT Model Selected Outcomes Discussion and Implications References

 
The development of a practice model for geriatric depression in rural primary care clinics was based on the research findings from Project IMPACT (Unützer et al., 2002). IMPACT's model of care included on-site, research funded, specialized professionals called geriatric depression specialists (GDSs), team collaboration, professional and patient education, and the utilization of practice guidelines. IMPACT demonstrated that a GDS present within a primary care clinic more than doubled the effectiveness of depression treatment for older adults. The placement and funding of these specialists at each clinic site was an important element of IMPACT. The GDSs were specially trained nurses and psychologists who acted as depression care managers. In this role, they collaborated with physicians to provide patient support, such as depression education and counseling, and follow-up care such as tracking side effects and helping coordinate medication changes.

Although IMPACT results for geriatric depression assessment and treatment were impressive, only one of the eight participating sites continued to use GDSs once the project ended (Saur et al., 2007). This may be accounted for, in part, by the influence of organizational culture on quality-improvement programs. According to Ferlie and Shortell (2001), interventions are most successful when culture is changed for complete buy-in of the improvement. For this change to occur, the inclusion of four organizational levels within the health care system is vital: the individual health professional, the health care team, the organization providing the health care (e.g., medical clinic, hospital), and the larger health care system or environment (e.g., private or public insurance coverage). Thus, despite IMPACT's success, the intervention may have lacked sustainability because primary care clinics could not or would not provide the additional staff and resources needed to continue the innovation.

Investigators from ADAPT—Assuring Depression Assessment and Proactive Treatment—met with IMPACT investigators to establish a working relationship and to modify IMPACT materials. A key adaptation for ADAPT focused on educating the existing clinic staff as GDSs instead of hiring additional staff to fill those positions as IMPACT had done. Another adaptation was the integration of geriatric depression assessment and monitoring forms with the clinical agency's own record-keeping system.

	The ADAPT Model

TOP Abstract Background The ADAPT Model Selected Outcomes Discussion and Implications References

 
Goals
With limited funding from the Health Resources and Services Administration, the Minnesota Area Geriatric Education Center (MAGEC) collaborated with its regional partners and IMPACT investigators to implement Project ADAPT in three rural regions of Minnesota. The goal of ADAPT was to develop and implement a pilot program in rural primary care clinics for screening, diagnosis, and treatment of geriatric depression that could be sustained beyond the pilot phase by building the capacity of existing clinic staff. The specific objectives of ADAPT were as follows: to utilize a multifaceted training approach incorporating didactic and experiential learning techniques to improve the knowledge and practice of depression assessment and treatment of primary care providers who care for older adults; to train designated staff from primary care clinics in three rural areas of Minnesota to screen, assess, treat, and manage depression in their older adult primary care patients; to develop a geriatric depression care implementation process that could be easily adapted to the rural primary care sites; and to design and implement an interdisciplinary training program for health professionals about the screening, assessment, and treatment of geriatric depression. These objectives were operationalized in the form of Project ADAPT, and University of Minnesota institutional review for the protection of human subjects was requested. Because no specific patient data with identifying information were submitted to the ADAPT team during the project, approval was granted through an expedited review process.

Essential Components of the ADAPT Model
ADAPT investigators developed key components of ADAPT in the following sequence. First, they assembled an interdisciplinary team for ADAPT development and execution. Second, they created a protocol and implementation process for patient screening and follow-up assessment, treatment, and ongoing management of older adults with a diagnosis of depression that could fit within the clinical site's current operating and documentation system. Third, they developed educational materials and training sessions about geriatric depression that were presented to existing primary care clinic staff in three rural Minnesota regions. Fourth, they designated a clinic staff person to be a GDS to interface with the patient and primary care provider to facilitate medical assessment of depression following a positive screen of depression, provide patient education as directed by the medical provider, and then access resources and provide community referrals for depression treatment. Fifth, the interdisciplinary ADAPT team provided ongoing consultation for the clinic staff during the 6-month implementation of ADAPT. Sixth and finally, the ADAPT faculty offered accessible at-home, telephone cognitive-behavioral group therapy for appropriate and interested patients as an option for depression treatment on referral.

The Interdisciplinary ADAPT Team
The ADAPT team included a geriatrician, a geropsychiatric clinical nurse specialist, a pharmacist, a geriatric clinical social worker, and the project coordinator. The deputy director of the Center on Aging at the University of Minnesota served as project coordinator. She coordinated efforts of the regional MAGEC offices in gathering potential site participants, organized training and educational materials, set up regional training sessions, served as primary contact for sites for questions, and processed the survey responses.

Protocol for Depression Care
The ADAPT Protocol for Depression Care contained the following components: screening, assessment, counseling, treatment, and follow-up.

For screening, the depression specialist administered the short form of the Geriatric Depression Scale (GDS-SF) to all patients 60 years of age and older. Guided by the literature (Sheikh & Yesavage, 1986) and the desire to include patients with minor depression, the ADAPT team had the depression specialist use a GDS-SF score of 6 or more—out of 15—to identify patients for further medical assessment of depression.

For assessment, the medical provider made an assessment of all patients with a GDS-SF score of 6 or more.

For counseling, the medical provider (or GDS, if appropriate based on professional training) discussed the GDS-SF findings, depression symptoms, and treatment options.

For treatment, the medical provider developed a treatment plan for depression management with willing patients. Although a treatment plan ultimately stems from the agreed-on decision between the medical provider and patient, treatment options discussed in the training sessions included both pharmacological and nonpharmacological options, as well as referrals to community mental health resources for psychotherapy.

For follow-up, the medical provider or GDS monitored patient symptoms, adjusted treatment, and provided support. The ADAPT team developed some suggested documentation guidelines and current procedural terminology (CPT) codes that could be used by the clinics to facilitate reimbursement for depression care. The team also developed materials to support implementation of the ADAPT protocol. These materials included region-specific resource lists for depression treatment referrals, depression assessment algorithms for assistance in making a diagnosis, and treatment protocol forms to cue the provider as to treatment options and to support the ongoing monitoring of patient progress.

Development of Educational Materials and Training for the Existing Primary Care Clinic Staff
The ADAPT team developed both professional and patient education materials on geriatric depression. Professional education materials to increase knowledge about geriatric depression included modules on types of depression, various depression screening tools, depression diagnosis, treatment options, and follow-up measures. Written materials provided to ADAPT participants included depression criteria set forth by the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994), a list of assessment tools, the 15-item GDS-SF—English and Spanish versions—and instructions for its use in screening for depression. The team also developed patient education materials for professionals to share with patients. These materials included patient education booklets and patient drug information and side-effect information sheets. Lastly, a CD-ROM containing all of the educational materials and ADAPT implementation protocols was provided for reproduction and to help participants educate their colleagues about geriatric depression.

During April 2004, the team provided 4-hour geriatric depression training sessions in three different rural locations. These training sessions were intended for professionals interested in learning more about geriatric depression and participating in the ADAPT project. During these sessions the ADAPT team used the educational materials already described, as well as experiential approaches, to instruct on how to use systematic protocols, the availability of various treatment options, and strategies for dealing with patients unwilling to confront their depression. Topics included an overview of depression and its impact on older adults, various depression scales used to screen for geriatric depression, criteria for diagnosis or assessment, and community-specific treatment resources. A detailed review of antidepressant medications included a discussion of benefits, drawbacks, and side effects, and an overview of nonpharmacological treatments for depression included an emphasis on behavioral therapies and lifestyle changes. The team explained the ADAPT project and protocols in detail and presented a clinic-based example of the implementation process.

A case example–role play allowed attendees to practice using the ADAPT screening, assessment, and patient follow-up materials. Lastly, these sessions included a lengthy question-and-answer period between the ADAPT team and attendees to discuss specific questions about the ADAPT materials and protocols, and specific implementation strategies for their particular practice sites. It was during this question-and-answer period that systemic clinical site barriers were addressed (e.g., time, reimbursement, and administrative support) and possible solutions discussed. Much of the discussion was driven by questions about how to integrate the role and responsibilities of the GDS into specific clinical sites.

Designation of a Specific Staff Person as the GDS
We defined a GDS as an existing medical assistant, nurse, social worker, or psychologist who would be trained to coordinate depression care for older adults. Coordination duties would include the screening function, the provision of patient education, arrangement of treatment referrals as appropriate, and follow-up inquiries (e.g., checking in with the patient, discussing side effects, and coordinating additional doctor appointments). GDS responsibilities beyond these roles could include counseling and medication management if the GDS was appropriately professionally trained. At the end of the regional training sessions, attendees were asked to participate in the ADAPT project and to identify themselves as potential GDSs for their site.

Provision of Ongoing Consultation
The 6-month implementation period began in June 2004—which was 1 to 2 months after the regional training sessions concluded—and ended in December, 2004. During that time, the ADAPT interdisciplinary team made itself available to all participants for follow-up consultation regarding implementation. The team gave the participants phone numbers, e-mail addresses, and fax numbers, and they encouraged them to contact the project coordinator and other team members to answer questions about implementing ADAPT protocols and to troubleshoot any early problems. The project coordinator also contacted the clinical sites (by phone or by fax, as e-mail was not always available in rural areas) on a regular basis to seek solutions to problems or concerns. Each site was contacted at least twice during the 6-month implementation period.

The Offer of Telephone Cognitive-Behavioral Group Therapy for Depression
ADAPT included a free, innovative option of telephone cognitive-behavioral group therapy treatment for interested and appropriate depressed older adults. This intervention was developed by one of the ADAPT team members (M. Kaas) as part of a funded pilot study designed to provide accessible depression treatment to older adults in their homes. Information about this option (as provided by a member of the ADAPT faculty) was given along with contact information during the regional training sessions and again by the project coordinator during phone contact with the clinical sites.

Recruitment
The ADAPT team partnered with MAGEC's seven Regional Geriatric Education Centers (RGEC) to identify three regions that met ADAPT criteria: rural designation, significant aged population, and primary care clinic(s) in the region. The team chose two regions located on the western edge of Minnesota (Northwest and Southwest) because they included large rural elderly populations with limited financial means, and a significant number of medically underserved communities. The third region (Southeast Minnesota) also included small communities with large elderly populations, many with limited financial means, along with two large health care service systems (Gunderson and Mayo Health) with community clinics throughout the region. RGEC staff members from these regions contacted all the primary care clinics in their region and invited them to participate in Project ADAPT and the geriatric depression education sessions provided in their region. In addition to invitational letters sent to the clinics, notices about the project and the training sessions on geriatric depression were published in area newsletters and RGEC e-mail mailing list server systems. Although ADAPT was specifically targeted to primary care clinics, public notices were also sent to hospitals, nursing facilities, home health agencies, and public health and social service organizations. Because few primary care clinic providers responded to the invitation to participate, and because multiple requests to participate came from providers in other health care settings, the ADAPT team expanded the regional training sessions and implementation of ADAPT to include a variety of clinical settings where depression screening and treatment could be accomplished.

ADAPT Participants
Fifty-six individuals from a variety of backgrounds (nurses, social workers, psychologists, physician assistants, certified nursing assistants, and behavioral health specialists) attended the regional ADAPT training sessions. Attendees represented 16 clinics or hospitals, 15 long-term-care facilities, 7 public health or home care agencies, and 6 county social service agencies. Attendees participated in the 4-hour training sessions and received a CD-ROM containing all the educational materials and ADAPT protocols. Although the RGEC invitational letters and notices explained the ADAPT project and responsibilities for participation, most attendees at the three regional sessions were not prepared to commit themselves or their agency to fully participate in the project. Many of the attendees came for the information about geriatric depression, heard about the ADAPT project, and wanted to return to their workplace to discuss the potential for implementation.

Requirements for participation in the ADAPT project were as follows. There had to be (a) administrative approval for ADAPT implementation from a supervisor, clinic manager, or medical director; (b) a designated staff person to be the GDS; (c) implementation of ADAPT protocols for depression care over 6 months; (d) consultation with the ADAPT team; and (e) participation in the project evaluation. People interested in participating were asked to provide their work contact information. After the regional training sessions the project coordinator contacted potential participants, and it was at this time most attendees decided to participate. In all, 44 clinical sites agreed to participate by completing the requirements just outlined here.

Evaluation of Project ADAPT
Evaluation of Project ADAPT included written and telephone surveys with results reported by site, not by respondent, to account for the possibility of multiple surveys from one site. Initially, information was collected through an anonymous written survey returned to the project coordinator. The written survey, which was mailed to each site at the completion of the 6-month implementation period, asked respondents to identify the components of the ADAPT protocol used at their site; to specify the number of patients evaluated for depression, both before and after the use of ADAPT assessment and implementation materials; and to indicate the number of depressed patients who accepted treatment after a positive screening or after further assessment. The follow-up telephone survey, which included all sites completing the written survey, took place 3 to 4 months later. Its purpose was to clarify problems and barriers related to the ADAPT implementation process.

	Selected Outcomes

TOP Abstract Background The ADAPT Model Selected Outcomes Discussion and Implications References

 
Fifteen of 44 clinical sites who initially agreed to participate in ADAPT returned the mailed survey. These sites included clinics (n = 3), hospitals (n = 2), public health agencies (n = 2), home care (n = 2), long-term care (n = 4), and county social service agencies (n = 2). Ten sites reported using some of the ADAPT assessment and implementation materials (e.g., GDS, patient education booklet, or treatment protocol form). Sites not using any ADAPT materials were primary care clinics and one hospital. Ten sites reported using a depression screening tool, and a total of 135 patients were screened during the study period. Of these, 59 patients were diagnosed with depression after being assessed. Seven sites (representing home care, social service and long-term care) reported using the GDS without modifications to screen patients and indicated that registered nurses and social workers administered the GDS. The GDS-using sites reported that 63 of the patients screened had a positive GDS score, with 45 patients subsequently treated for depression and 8 patients refusing treatment. The other sites did not report any information related to treatment.

The patient education booklet was the most used material for the treatment and counseling component of the ADAPT protocol, with five sites reporting using this information. No site reported using the assessment algorithm, treatment and monitoring protocol form for cuing the providers, or the documentation and CPT coding guidelines to aid in billing for geriatric depression treatment. Likewise, no clinical agency requested consultation from the ADAPT team during implementation and no agency referred patients to the telephone group therapy. Although none of the clinical sites adopted the entire ADAPT protocol for depression care with all the supporting materials during the 6-month implementation period, sites using some components (though not necessarily following the protocol) indicated that their overall knowledge and skills in depression screening had improved and the numbers of patients screened increased (yes–no questions). GDS-using sites reported that the nurses and social workers who performed the screening neither identified themselves as the GDS nor completed the other treatment and or counseling responsibilities of the depression specialist.

All 15 sites that completed the written survey subsequently participated in the follow-up telephone survey. Eight sites reported earlier identification of geriatric depression and better communication about depression with the primary provider as a result of participation in the ADAPT project, and four sites reported improved treatment follow-up with patients diagnosed with depression. Participants who completed the telephone survey also identified several barriers to ADAPT implementation: patients' unwillingness to accept treatment recommendations (6 sites); lack of health care provider time to screen, assess, and manage the depression in older adult patients (6 sites); and providers' resistance to using ADAPT protocol forms (3 sites).

Approximately 20% of patients who received a follow-up medical assessment for depression by the primary care provider, after being screened by other clinical staff, refused treatment for their depression. Both mail and telephone survey participants reported that patients did not believe they were so depressed that they wanted medications, the primary treatment offered. In some regions, the option of psychotherapy meant a drive to another city, and no agency referred patients to the at-home telephone group for depression.

All of the sites suggested, either in writing or by telephone, additional strategies to make the implementation of ADAPT more successful. These recommendations included the following: more agency administrative support, additional one-to-one contact with the ADAPT team, additional communication tools for use in the clinical setting to facilitate continuity of assessment and treatment, additional training by the ADAPT team to tailor the model and the GDS's role to meet the needs of particular sites, and training to minimize patient resistance to depression treatment.

	Discussion and Implications

TOP Abstract Background The ADAPT Model Selected Outcomes Discussion and Implications References

 
We expected some enthusiasm for the regional geriatric depression education sessions because of strong interest expressed by the RGECs for geriatric education workshops and mental health training programs. However, we also expected more primary care clinics to volunteer for ADAPT because geriatric depression had been previously identified as a concern by the Minnesota Medical Association, RGECs, Area Agencies on Aging, and by health and social service providers who expressed interest in learning more about geriatric depression as a result of several depression-awareness campaigns conducted by the Minnesota Board on Aging. The scope and funding of ADAPT did not permit additional efforts to recruit individual clinics or allow individual, on-site clinic training visits by ADAPT personnel, although that was cited as a need by some participants in the evaluation. Follow-up phone contact with clinical sites that declined to participate suggested that limited staffing and patient overload were the primary reasons for nonparticipation. Although we hoped for interested participants, we knew that these participants could not be considered leaders or champions for ADAPT at their site. Limited by time and resources, we could neither target a supportive leader or administrator at each site nor develop the relationships necessary for a health system buy-in. Our results are not surprising given these, and other, suggestions made by Ell in her review article on reducing the barriers when trying to translate depression care research into practice (Ell, 2006).

Implementing ADAPT in three diverse regions of Minnesota limited the time the team could spend with individual clinical sites, which were geographically distant from one another. Focusing on one region would make training efforts more efficient and could more easily foster the development of support networks between ADAPT users and the sharing of resources across sites—elements not emphasized in the current study. A one-region approach could also have provided the ADAPT team with more communication opportunities with ADAPT users, leading to a stronger relationship between rural practice and urban academic communities. The lack of any clinic or agency referral of patients to the free, at-home, telephone group therapy may have resulted from inadequate education about this nontraditional form of treatment. More information, guidance, and support to the GDSs to initiate its use could have promoted access to this treatment option.

The refusal of depression treatment by almost 20% of persons diagnosed with depression by their primary care provider in this study is consistent with studies of treatment preferences (including the findings of IMPACT) among patient populations of all ages, especially older adults (Lants & Buchalter, 2004; Van Voorhees et al., 2005). Many rural Minnesotans have a strong Norwegian ethnicity noted for its focus on self-sufficiency and stoicism. Refusal of treatment may also be linked to cost. Prior to Medicare Part D, many older adults not poor enough to be covered by Medicaid lacked prescription drug coverage. Although the aforementioned characteristics of elders also occur in areas that are not rural, refusal for care in rural Minnesota can stem from increased difficulties related to greater travel time, limited public transportation options, and harsher weather conditions (Office of Rural Health & Primary Care, 2005). Furthermore, with the scarcity of psychiatrists in the rural setting, telephone consultation is not a practicable option because it is not covered under current third-party reimbursement policies. Minnesota rural primary care clinics that are Medicare certified receive only 50% of the costs for mental health services. Thus, rural health clinics are reluctant to offer mental health services (Office of Rural Health & Primary Care, 2005).

The number of alternative care sites that expressed interest in Project ADAPT suggests they are well aware of the barriers to accessing traditional mental health care in rural areas, and it reinforces the need for a nontraditional system of care by rural clinical sites. Many of these non-primary-care-clinic sites (e.g., public health agencies, long-term-care facilities) were very interested in addressing geriatric depression with the patients they served; however, the ADAPT protocols and materials did not always fit their systems of care, despite efforts to modify materials. The fact that many of these sites were not closely connected to primary care clinics presented another challenge to the continuity-of-depression-care model (screening, assessment, treatment, and follow-up) originally envisioned by ADAPT. These non-primary-care clinical sites are critical to the delivery of rural health care, yet they present both challenges and opportunities to integrated care, as the success of the Program to Encourage Active, Rewarding Lives for Seniors demonstrated for minor depression care in homebound older adults (Ciechanowski et al., 2004). The need to tailor approaches to depression intervention in these settings and the challenge and rewards of collaborating with medical and psychiatric providers across clinical settings has been recognized in other areas of the aging network, specifically in home care and nursing home care (Ciechanowski et al.; Meeks, Jones, Tikhtman, & La Tourette, 2000; Quijano et al., 2007).

The professional background and clinical qualifications of ADAPT participants were known; however, their ability to train others in the protocols was unknown. The educational materials (CD-ROM) were developed to facilitate participant learning and encourage "train the staff" teaching approaches, but we neither formally assessed the capability or willingness of participants to train other clinic personnel nor assessed their ability to conduct the GDS or to implement other components of the ADAPT protocol. We discovered it was difficult for participants, who were typically staff employees of the clinical sites, to implement changes without the specific support of the management team. The staff members who attended the regional training sessions generally believed they were sent to learn about geriatric depression and to participate in the project, yet many reported later that the management support needed to make system changes to successfully implement ADAPT was not there. Future efforts to enact systemwide practice changes should include a component focused on changing organizational culture to facilitate the development of new system processes to support the practice change.

Conclusions
This study demonstrated that there is considerable interest in identifying and treating geriatric depression in rural health care settings outside of the traditional primary care clinic. Additionally, it reinforced the need for depression protocols and materials designed to meet the specific needs of clinical sites. However, a clearly identified need, education, and clinic-specific and provider-designed tools may still not be enough to change clinical practice. Clearly it takes an entire clinical system to raise awareness and make changes. Barriers include inadequate medical provider and management support, inadequate time and reimbursement for the depression care provided, inadequate or inappropriate staffing for the depression care needs of older adults, and patient reluctance to be labeled with a diagnosis of depression and subsequently accept treatment. Despite these challenges, opportunities to achieve the goals identified in the ADAPT project should be pursued in a variety of clinical settings. Non-primary-care settings may have more system flexibility, more time to spend with individual clients or patients, and more access to regular patient contact. Specific interventions should be developed to obtain physician and upper-level management buy-in, to modify clinical system processes to support practice changes, and to address patients' reluctance to accept care for a substantiated diagnosis of depression.

	Footnotes

 
This study was supported by the Health Resources and Services Administration. We thank Robert L. Kane, Anne Kane, Dean Neumann, and others at the University of Minnesota Center on Aging and the Minnesota Area Geriatric Education Center (MAGEC), MAGEC's regional partners, and Holly Ashmore, Master's student in Public Health at the University of Minnesota, for their contributions in conducting this project.

¹ University of Utah College of Social Work, Salt Lake City.

² University of Minnesota School of Nursing, Minneapolis.

³ INGENIX, Research & Development, Eden Prairie, MN.

⁴ Department of Family Medicine and Community Health, University of Minnesota, Minneapolis.

Decision Editor: Nancy Morrow-Howell, PhD

Received for publication March 18, 2007. Accepted for publication August 1, 2007.

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TOP Abstract Background The ADAPT Model Selected Outcomes Discussion and Implications References

 

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