Appendix D:
Implementation and Training Plans
Appendix D: Implementation and Training Plans
Appendix D: Implementation and Training Plans
 Implementation Plan
1. Introduction ................................................................................................... D1
2. Core Implementation Ingredients ................................................................. D2
o Depression Screening .............................................................................. D2
o Referral and Recruitment ........................................................................ D3
o Measurement-Based Outcome Assessment ............................................ D7
o Staffing .................................................................................................... D7
o Agency Education ................................................................................... D8
o Training and Technical Assistance ......................................................... D9
o Clinical Case Review .............................................................................. D9
o Funding Challenges and Opportunities ................................................. D10
3. Implementation Management Team ........................................................... D12
4. Program Evaluation .................................................................................... D13
5. Organizational Mission ............................................................................... D14
 Training Plan
1.
2.
3.
4.
5.
Overview ..................................................................................................... D15
Audience ..................................................................................................... D16
Methods ....................................................................................................... D17
Content and Time ........................................................................................ D19
Other Training Options ............................................................................... D22
Appendix D: Implementation and Training Plans
Implementation Plan
Introduction
Despite the existence of effective treatments for geriatric depression, spread or translation of these
interventions into everyday practice has been slow. Translation of evidence-based practices occurs
in organizations and systems that exert influence on the implementation efforts and thus can affect
the outcome of those efforts. A key step in the successful translation of an evidence based practice
like PEARLS is the ability of the organization and system to overcome barriers to intervention
implementation that exist inside and outside of organizations. The purpose of this implementation
plan is to identify some of the common obstacles that occur when organizations attempt to
implement PEARLS and to provide some suggestions on strategies to overcome these obstacles.
Much of the information included in this section comes from the University of Washington Health
Promotion Research Center’s experience providing technical assistance to PEARLS providers and
conducting translational research to better understand barriers to PEARLS implementation and test
strategies for addressing these common obstacles. These provider agencies include aging and social
service agencies such as area agencies on aging, senior centers, community mental health centers,
and other community-based organizations. In preparing this PEARLS Implementation Toolkit, the
PEARLS research team also convened discussions with representatives from five Area Agencies on
Aging (AAA) of Washington State, thus benefiting from the experience of those quite familiar with
PEARLS and the realities of real world providers. Lastly, a member of the PEARLS research team
currently provides clinical supervision to five local PEARLS sites, providing rich data on common
implementation issues and solutions.
This Implementation Plan is divided into the following sections:

Core implementation ingredients: Depression Screening, Referral and Recruitment,
Measurement-Based Outcome Assessment, Agency Education, Staffing, Training, Clinical
Supervision, and Funding

Implementation Management Team: Identifying a staff person or team to coordinate
PEARLS implementation

Program Evaluation: RE-AIM, an overall evaluation approach for PEARLS
implementation
D1
Appendix D: Implementation and Training Plans

Organizational Mission: Things to consider when deciding whether PEARLS is
appropriate for your organization
Core Implementation Ingredients
The core components of the PEARLS treatment program delivered by the PEARLS counselor
include:

Problem Solving Treatment (PST)

Social and Physical Activation

Pleasant Events Scheduling
However, in order to successfully implement and manage the PEARLS program, an organization
must also effectively provide for:

Depression Screening

Referral and Recruitment

Measurement-Based Outcome Assessment

Staffing and Agency Education

Training and Clinical Supervision

Funding
Depression Screening
The PEARLS model was specifically designed to include active screening for depression in your
organization. Depression is often unrecognized, particularly in older adults. It is considered a
normal part of life, as opposed to a clinical disease for which there are effective treatments.
Incorporating a validated depression screening tool into your organization’s current screening
assessments is important for identifying people with depression and potential PEARLS clients.

D2
The PHQ-2, the first two items of the PHQ-9 depression screen, is a brief tool for screening
potential clients for depression. The PHQ-2 consists of the first two questions on the PHQ-9:
“Over the past two weeks, how often have you been bothered by any of the following
problems? 1) Little interest or pleasure in doing things and 2) Feeling down, depressed or
Appendix D: Implementation and Training Plans
hopeless.” Response choices can be Yes/No format or the same four response choices used
in the PHQ-9 (0 = Not at All, 1 = Several Days, 2 = More than Half the Days, 3 = Nearly
every day). Clients screen positive for depression if they answer “Yes” on the Y/N version,
or a “2 or 3” on the four-response version.
The purpose of the PHQ-2 is as a depression screen. People who screen positive should be
further evaluated with the PHQ-9 to determine whether they meet criteria for minor or major
depression.
Several PEARLS sites have trained their staff or other social service organizations to
administer the PHQ-2. For instance, in San Diego, meals on wheels delivery drivers have
been trained to administer the PHQ-2 to their clients or have the client self-administer the
tool. The completed survey is then given back to the aging services organization who
follows-up with the client about PEARLS if their screen positive for depression.

The PEARLS program uses the PHQ-9 to screen for depression and to track client outcomes
at each PEARLS session. If you organization has time to administer the full PHQ-9 to a
client during active screening, this is an ideal tool as it will provide information about
whether a client meets criteria for minor or major depression.
For example, the Washington State Aging and Disability Services Administration uses the
PHQ-9 as a depression screening instrument in their regular assessments of case management
clients using home and community-based services. Clients who receive a total score of 4 or
more are referred to PEARLS for further eligibility screening if they appear to meet other
program criteria (e.g., normal cognitive functioning).
We recommend training all staff that will be using the depression screening tool on appropriate
screening methods and being sensitive to possible client stigma about depression. For instance,
screening should be conducted in a private setting and clients should be assured that their responses
will be kept confidential. Periodically monitor the screening process and adjust screening methods
accordingly.
Referral and Recruitment
The Recruitment and Screening section of the PEARLS Implementation Toolkit reviews several
methods for recruiting clients for PEARLS, including regular screening for depression, cultivating
community relationships, and creating and sharing printed materials such as flyers and introductory
D3
Appendix D: Implementation and Training Plans
letters about the program. Here are several other things to consider when planning your
organization’s recruitment strategy:
D4

Use materials and media that are appropriate to your target community and put a face on the
program. For instance, put photos of your PEARLS counselor(s) on flyers or publish client
stories in your organization’s newsletter or in local community newspapers that serve your
client population. Seattle’s International Drop-In Center interviewed a PEARLS counselor
on community radio program popular with their target Filipino community and received
many self-referrals using this culturally relevant strategy. Consider using appropriate
wording that is sensitive to potential stigma around mental health (e.g., “mood” or “emotion”
instead of “depression”; and “wellness care manager” or “coach” instead of counselor).

Conduct presentations with other program providers who serve your PEARLS target
population, such as senior housing, meals on wheels, or information and assistance lines.
Presentations may also be made to potential clients (e.g. a depression education seminar at a
community exercise class) and to other practitioners (e.g., at trainings that provide continuing
education for social workers). Take advantage of promoting PEARLS in May, which is both
mental health month and older adults month.

When screening potential PEARLS clients, review their current functioning, as opposed to
looking at what is in a client’s file. This is particularly important when reviewing other
disorders such as substance abuse, cognitive impairment and other psychiatric conditions.
Some disorders may no longer be present or are currently being managed, making the client
stable and able to do PEARLS.

Use multiple referral mechanisms (such as self-referral, referral through other programs, and
referral through your agency’s case managers) to help cast a wide net for recruitment. Keep
track of where your organization’s PEARLS referrals are coming from (e.g., in-house, senior
housing, Adult Protective Services). Regularly monitoring the referral source is key for
reaching potential clients and adjusting efforts accordingly.

Your organization may need to expand PEARLS program eligibility criteria as appropriate in
order to best reach your client population. As described in the Background on PEARLS
section of the PEARLS Toolkit, recent research has demonstrated similar outcomes as the
original PEARLS research study when delivering PEARLS to younger clients, clients with
epilepsy and co-occurring depression, clients with major depression, and clients with limited
English proficiency (through both native-language speaking counselors and English-speaking
Appendix D: Implementation and Training Plans
counselors with an interpreter). Modifications were made to the program policies and
procedures as needed when expanding the eligibility criteria. The University of Washington
is not in a position to license or approve your local program adaptations. When thinking
about adaptations, do what makes sense for your agency, your client population and your
local implementation issues; then, monitor program outcomes to assure that the program is
still working effectively.

Normalize PEARLS recruitment rates (for your agency and for your funders) given the target
population that PEARLS serves. PEARLS targets frail, homebound adults with multiple
comorbidities and barriers to care. PEARLS differs from other evidence-based practices that
are located in clinic settings which have larger populations from which to get referrals and
tend to have healthier clients since they are able to attend clinic visits.
Once clients are recruited into PEARLS, several strategies can help with keeping clients enrolled in
the program and minimizing dropout rates:

Use the above strategies to improve the number of appropriate referrals to PEARLS. This
is preferred to flooding the program with referrals that do not meet program criteria as this
can discourage referring providers when their clients do not enroll and/or face a long wait list
to enroll.

Bend over backwards to keep enrolled clients in the program. Since most PEARLS clients
have no other depression treatment option, we encourage providers to be flexible to meet
client’s needs once they are enrolled in PEARLS.
o For example, counselors may need to “pause” the sessions when a client falls ill and
needs to be hospitalized for a month. Once the client returns home, resume PEARLS
sessions, possibly increasing the frequency at first to get the client back on course with
learning and practicing the PEARLS skills.
o Another case of being flexible is emphasizing the behavioral activation arm of PEARLS
if the client struggles with doing PST. We agree that those unwilling to consider PST at
screening may not be appropriate, but once someone is enrolled in PEARLS we
recommend emphasizing exercise, pleasant events, socialization before disenrolling a
client who is not doing PST. PEARLS counselors should still try and engage the clients
in PST at each PEARLS session as the client’s motivation and willingness may change
over time as their depression gets better. The PEARLS Tracking Chart (Appendix B6)
D5
Appendix D: Implementation and Training Plans
includes the other PEARLS arms (physical activity, social activity, pleasant events) in
addition to PST.
D6

Track reasons for client dropout to inform subsequent approaches for addressing dropout
rates at your organization.

Working with clients with cognitive impairment: Occasionally, some clients pass the
cognitive screeners (6-item or MMSE) and later show signs of mild cognitive impairment
during the PEARLS sessions. Several strategies can be used to continue to work with this
client: work with their caregiver (e.g., have clients share the PST worksheets and action plans
with their caregiver), focus on the non-PST arms of PEARLS (e.g., behavioral activation),
and work with clients that can retain information between sessions even if have some mild
cognitive impairment. If by the third or fourth session the client is still not improving, readminister the cognitive screens to assess whether cognitive impairment is the issue or
something else is going on (e.g., the PEARLS counselor is setting the treatment plan for the
client or there has been unrecognized substance abuse).

Strategies for working with low-literacy clients include reading worksheets aloud and
having others help fill out the worksheet (such as a counselor or caregiver). Be mindful of
what is written when others will read the worksheets. When asking the client about reading
and writing, frame the question in relation to vision issues instead of a lack of education. In
addition to low literacy clients, some clients with limited education, from rural communities,
and/or from immigrant communities are reluctant to complete all of the PEARLS paperwork
and may find the paperwork overwhelming. Use the strategies for low literacy clients and
balance the clients’ opinions of the paperwork with engaging them to learn the PEARLS
skills.

In some cases it is appropriate to disenroll the client early from PEARLS, such as if they
move or enter a long-term institution such as a nursing home. This should be tracked
differently than a dropout in your program tracking system.

It may be appropriate to graduate some clients early from PEARLS if they have maintained
significant improvements in their depression symptoms (e.g., response or remission) over at
least one monthly session. Graduating a client early (after the sixth or seventh session) may
be needed for capacity reasons to free up your PEARLS counselor’s time for new clients.

Several approaches are recommended for working with rural populations and/or large
geographic target areas. Assign counselors based on specific geographic regions; use
Appendix D: Implementation and Training Plans
phones for pre-screening and confirming appointments; use electronic medical records and
laptops to systematize data tracking; and combine multiple home visits in a similar
geographic area in one day.

Focus on treating depression in clients with multiple issues. For some clients, another
condition such as grief or anger presents more strongly than their depression. PEARLS has
demonstrated effectiveness for treating depression only. Focus on treating client’s
depression and, in turn, they may be able to begin addressing some of these other issues.
PEARLS counselors are encouraged to train the client use PST to address these concerns as
well.

In the screening for exclusionary conditions, ask about beer and wine specifically as some
clients do not consider beer or wine to be “alcohol” and will answer “no” to the substance
abuse screen.
Measurement-Based Outcome Assessment
Tracking PHQ-9s and other processes/outcomes is described in the Recruitment and Screening,
PEARLS Sessions, and Data Management sections of the Toolkit.
It is also important to track your organization’s fidelity to the PEARLS research model. The
University of Washington HPRC recently developed and is testing a brief, 20-item fidelity
instrument for PEARLS. This tool was created after interviewing PEARLS researchers, staff and
former clients to identify key program components. This instrument is still in development, but
contact uwpearls@uw.edu for more information.
Staffing
The PEARLS program can be delivered by a number of trained personnel. In the research study,
master’s level social workers and a registered nurse were effectively trained to be PEARLS
counselors. Their training took 3-4 days in order to achieve the rigorous fidelity ratings necessary
for the research study. It is not expected that this duration would be required outside of the research
setting. Nevertheless, one should anticipate that training of 1-3 days will be necessary for most staff
looking to become PEARLS counselors. Familiarity with much of the material of this toolkit may
save substantial time and accelerate learning during the PEARLS training sessions (an outline of the
training is described in the Training Plan). Case managers already employed to work with clients
who are interested in becoming PEARLS counselors can be trained to deliver the program. As
mentioned previously, the nature of the work with the client is client-driven and depends on the
D7
Appendix D: Implementation and Training Plans
client generating their own solution strategies and carrying these out independent of the counselor.
Thus it is not recommended that case managers serve as PEARLS counselors for clients that they are
already providing case management as this may blur the roles in the minds of both the client and
counselor.
Some successful models for staffing PEARLS include: using outreach workers to build relationships
and get referrals, using Master’s and PhD-level interns as PEARLS counselors (unpaid interns
receive necessary clinical hours and supervision for graduate program), hiring fewer counselors at
first until caseload increases, training program administrators as well to help with staffing
transitions, and providing mental health consultation to other programs that serve older adults (e.g.
Adult Protective Services, senior centers).
While coming to PEARLS training with some background and experience in mental health
counseling may be advantageous, there are also some potential drawbacks. PEARLS is a quite
structured treatment program that requires the counselor to be focused on following the 7 steps
identified and not to overly combine the PST approach with other forms of psychotherapy.
Similarly, counselors with experience in more therapist-directed treatments or, who out of their own
personality types view their role as to solve the client’s problem, may have difficulty adhering to the
principles of the PEARLS program. In practice, we have found that PEARLS counselors with
bachelor’s-level training and/or with limited mental health background and experience can do
PEARLS, provided they receive formal PEARLS training and have regular clinical supervision.
Agency Education
To prepare agency staff for implementing PEARLS, it is important to balance providing enough
information with the need not to overly impose on the time and work schedules of all staff. As such,
having a brief 20-30 minutes presentation on PEARLS delivered by a “PEARLS expert” (one of the
staff that attended the PEARLS training or one of the professionals associated with the original
research study) is felt to be ideal. This can serve to emphasize the evidence-based nature of the
program and present “the facts” supporting its use. In discussions with representatives from AAAs,
it was felt that though many people could present the research data, having a psychiatrist associated
with the program do so adds credibility. And, by virtue of this person taking their time, it gives
added emphasis to the importance of the program. Additionally, it is important for staff of the AAA
or other type organization implementing PEARLS to speak to the specific features of the
organization that support offering the PEARLS program. It is impossible for the limited number of
professionals associated with the PEARLS program research to meet the potential needs for
presentations on PEARLS in all the geographic areas that may be interested. Thus, use of
D8
Appendix D: Implementation and Training Plans
communications technologies such as video media presentation, video and teleconferencing and
web-based presentation will become increasingly important. Supplementing these presentations
with written materials, such as a poster presentation of the PEARLS research and parts of this
Toolkit, that provide basic background information on PEARLS is also recommended.
Training and Technical Assistance
PEARLS trainings are currently provided twice a year in Seattle, Washington, by Training Xchange
at the University of Washington. Training Xchange also offers several online modules to use for
pre-training, booster training, and supplemental training of new PEARLS staff. Brining trainings
on-site to an agency or group of agencies is also possible; contact Training Xchange for more
information on pricing and availability. More information about training is provided in Training
Plan, beginning on page D15.
Having available good clinical supervision from someone quite knowledgeable of PEARLS is an
essential component of ongoing staff training. Using the counselor self-assessment forms provided
in this Toolkit can also support the training of PEARLS counselors as they will be reminded of the
specific program tasks and skills when using this form and identify individualized areas for
improvement.
The PEARLS Technical Assistance Center at University of Washington Health Promotion Research
Center currently offers monthly technical assistance conference calls to PEARLS programs that have
completed the PEARLS training. These calls provide a platform for discussing common PEARLS
implementation questions and networking with other PEARLS programs. Training Xchange also
offers contracts for tailored technical assistance for individual agencies.
Clinical Case Review/Supervision
As described previously, ongoing clinical case review/supervision is an essential component of the
PEARLS model. Clinical supervisors provide regular support and consultation for PEARLS
counselors’ new and ongoing client cases. They help reinforce the PEARLS client-driven model,
working with staff to ensure that their PEARLS counselor role is separate from their case
management role. They are also available to contact the client’s physician and medical team
regarding possible changes to antidepressant medications.
It may be challenging to find a local psychiatrist to serve as the clinical supervisor for your
organization. Conference calls and Skype-based procedures are appropriate for PEARLS clinical
case review/supervision sessions with groups of PEARLS counselors, because clinical supervisors
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Appendix D: Implementation and Training Plans
are reviewing cases rather than seeing clients directly. Possible resources for supervisors include
local universities or academic medical centers with psychiatrist trainees and/or geriatric psychiatrists
that have been trained to provide supervision as part of their training. Explore low-cost or free
supervision agreements, such as exchanging PEARLS program data for university research
purposes, or having PEARLS clinical supervision count towards required hours for a psychiatrist
training program. Another potential source for clinical supervisors is a local IMPACT program.
IMPACT is a primary care-based depression care management program for older adults. The
IMPACT model uses a similar clinical supervisor as the PEARLS model, and this person will
already be familiar with PST, behavioral activation, and other components of PEARLS. Visit
www.impact-uw.org to see if there is an IMPACT program near your organization.
More information about clinical case review/supervision is provided in the main section of the
Toolkit on pages 94-100.
Funding Challenges and Opportunities
There are not readily available sources of funding for PEARLS. In the research study of the
effectiveness of PEARLS, the costs of the counselors, which included a registered nurse, were
covered by the research grant. The study estimated the costs of the PEARLS intervention counselors
and supervising psychiatrist to be $630 per client. Note that this does not include the funding
support necessary for recruitment and screening of all the patients who ultimately were not eligible
or declined participation in the research study. Estimates from current PEARLS programs suggest
that costs per client are closer to $1,300.
Other opportunities for possible funding were identified in technical assistance calls and in
discussions with AAAs in the preparation of this Toolkit update are:

Medicare: Generally speaking, Medicare reimbursement would cover services provided by
doctoral level psychologists or psychiatrists, nurse healthcare specialists (such as advanced
registered nurse practitioners) or master’s level licensed clinical social workers. It is quite
feasible to train any of these practitioners to serve as PEARLS counselors and the PEARLS
research study did use some master’s level social workers as counselors.

Medicaid Waiver for Ancillary Services: Within the Medicaid funded public mental health
system of Washington State, there are not the same limits on the types of providers. But, the
access to care standards across the state are based on diagnosis and severity of illness criteria,
which typically may not include services for Medicaid recipients having minor depression or
D10
Appendix D: Implementation and Training Plans
dysthymia. Washington State has recently secured funding for PEARLS as a Medicaid
waiver service, called “COPES.” Clients that receive case management through home and
community based services may be eligible for COPES services based on their annual
assessment. PEARLS is covered as an education and skills training service for clients with
minor depression. COPES reimburses for a “human services professional” (no graduatelevel training specified) to deliver eight in-home sessions plus an additional recruiting and
screening in-home session. In Washington State, PEARLS must be provided through
COPES vendors outside of the area agency on aging. We do not know of other states
covering PEARLS through Medicaid waiver funding at this time, but believe this could be a
potential source for PEARLS funding in other states.

Mental Health Federal Block Grant Funding: The mental health division federal block
grant dollars are specifically designated to provide for services not covered by the Medicaid
program and are allocated by the state Mental Health Division through a grant application
process. PEARLS would fit this definition and organizations could apply for this funding by
working with the mental health regional support networks in their geographical locations,
since the majority of service delivery block grant funding is distributed via the regional
support networks that contract with the state mental health division to provide services to
their respective regions of the state. Some AAAs have already successfully partnered with
these networks to establish depression screening programs that include some brief treatment.

Grant Funding: Some PEARLS programs have supported program implementation through
research grant funding or a local foundation or endowment focused on mental health, aging,
and/or epilepsy. Research grants might involve partnering with a local university to test a
new research question about PEARLS, such as how to adapt the PEARLS model to
implement with a new client population or evaluating a phone or Skype-based PEARLS
model for reaching rural populations.

Special Funding Allocations from within the Organization’s Discretionary Budget: In
one urban AAA, the PEARLS program has been continued with funds allocated directly from
the AAA discretionary budget as authorized by their advisory council. This funding helps
support program staff.

Voter-Approved Funds: Several PEARLS programs have received support from voterapproved funding for local government services. In 2008, Seattle-King County approved a
property tax levy to support PEARLS programs for veterans and veterans’ spouses and
underserved ethnic minority communities. In 2004, California voters passed the Mental
D11
Appendix D: Implementation and Training Plans
Health Services Act (or “Millionaires Tax,” an income tax on residents earning more than
$1,000,000 per year), which supports several PEARLS programs throughout the state.
Thus, securing funding for the PEARLS program typically involves multiple funding sources and
varies for different types or organizations and geographic areas.
Implementation Management Team
Even when funding for PEARLS has been obtained, there are ongoing barriers to implementation
that must be overcome. For this reason, clearly identifying an implementation management person
or team is crucial. During the successful research study demonstration of PEARLS’ effectiveness,
many of these barriers (e.g., patient recruitment, data management) were handled by the research
staff funded by the research grant. In the real-world dissemination of PEARLS that has continued
beyond the research study, the tasks of organizing and directing the program are left to the adopting
organization and compete with the numerous other organizational priorities. The implementation
manager needs to have a thorough understanding of the PEARLS program but also needs to be
positioned within the organization implementing PEARLS so that he or she can secure and direct the
resources needed to sustain the program.
Typical duties of an implementation manager or management team would include:

Hiring of PEARLS staff

Educating agency staff about PEARLS

Arranging for training and supervision of PEARLS staff

Establishing the referral and recruitment protocols

Establishing the data management system

Monitoring and reporting on program activities and outcomes
Program Evaluation
Ongoing evaluation of program outcomes is essential to assure that the program is providing the
desired benefits. The PEARLS Toolkit section, Data Management, details many of the individual
variables and forms that are necessary for your organization to have a broad array of data for
reporting program successes.
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Appendix D: Implementation and Training Plans
Here we will provide an overall evaluation approach using the RE-AIM framework that is becoming
increasingly popular in evaluating dissemination of evidence based practices.





Reach
Effectiveness
Adoption
Implementation fidelity
Maintenance
The extent of the program’s reach can be determined by tracking the proportion of clients identified
as depressed (through the screening system) that eventually receive treatment. As a program for
treatment of depression, the primary outcome of effectiveness is the change in the PHQ-9 depression
score from baseline to the final assessment. However, other, secondary outcomes are very important
to track and include changes in levels of pleasant events scheduling, and physical and social
activation. Participant satisfaction and in particular, the qualitative statements they make about how
they have benefited by participating in the program are powerful parts of the evaluation. PEARLS
was not designed to save health care dollars but the research supporting its effectiveness suggest that
it may reduce overall (non-psychiatric) hospitalization rates and expenditures for participants. Thus,
depending on the size of one’s organization or the evaluation perspective (e.g., statewide), it may be
important to evaluate hospitalization data. Adoption of the PEARLS program refers to how well the
program spreads throughout the organization. For example, are clients of all case managers likely to
be included or do only a limited number of case managers adopt or use the program?
Implementation fidelity is determined by evaluating how closely the program adheres to the
evidence based practice model; a PEARLS Fidelity instrument has been developed and is being
validated by the University of Washington Health Promotion Research Center. It is also possible to
determine how well the program practices as described in this Toolkit are carried out on a day-today basis. For example, the organization can determine if the clients that are enrolled clearly have
depression or whether the program moved to enrolling other types of participants. Are the PHQ-9
scores obtained consistently in every PEARLS session? Are there processes in place for psychiatric
supervision of the counselors? Maintenance of the PEARLS program refers to the sustainability
over time of the program and can be determined by tracking the years, numbers of participants
enrolled annually across the history of the program.
Organizational Mission
Successful implementation of PEARLS starts with a thoughtful, deliberate process to determine that
implementing PEARLS is the right thing to do. Like most important activities of an organization,
D13
Appendix D: Implementation and Training Plans
PEARLS will require all levels of an organization, from front-line staff working directly with clients
to administrators directing staff, to work together. All parties need to be equally informed about data
and decisions supporting the need for the PEARLS program and be motivated to address the need.
While many organizations serve depressed older adults, the research that supports PEARLS does not
necessarily generalize to all settings and all older adults with depression. Similarly, not all
organizations serving older adults have treatment of depression as part of their mission. Thus, a first
step in deciding to implement PEARLS is to determine the fit of the objectives of PEARLS with the
mission of one’s organization.
Commonly recognized organizational mission factors that particularly support a decision to adopt
the PEARLS program include being concerned with:

Maximizing overall health, which includes emotional health

Focusing on the most common problems of older adults

Empowering clients to direct their own recovery
As a part of overall health, meeting the mental health needs of older adults will be important to many
health care organizations that do not necessarily see themselves as mental health providers.
Clinically relevant depression occurs commonly, in as many as 20-30% of home bound elderly who
qualify for in-home services and in 50% of people with epilepsy. Thus, because there is as a need
present in a large number of an organization’s clients, a decision may be made to adopt PEARLS. If
it is unclear how prevalent depression is in a specific program’s population, conducting an initial
screening study may be helpful. By administering a validated depression screening instrument such
as the PHQ-9 found in this toolkit to all or a representative sample of an organization’s clients,
organizations can get a clearer sense of how common depression is and thus make a more informed
decision. Unlike some forms of case management and mental health counseling, PEARLS strives to
empower the client to direct their own recovery and to learn skills that can be used well beyond the
acute treatment phase. The problems and solution strategies that are selected in each of the PST
sessions are those chosen by the client, not by the counselor. Similarly, the pleasant events, social
and physical activities chosen are selected by the client to optimize their relevance and likelihood of
being accomplished.
As mentioned, PEARLS is a treatment that is delivered typically in 6 to 8 face-to-face sessions over
a period of time that covers 5-6 months. Thus, organizations that have much briefer contacts with
older adults may find that PEARLS is not a good fit because of the duration of time it requires.
D14
Appendix D: Implementation and Training Plans
Training Plan
Overview
This Training Plan provides guidelines in the methodology, content, and processes for training staff
involved in the implementation of PEARLS within your organization. The plan is designed to work
hand in hand with the PEARLS Implementation Toolkit, which provides detailed guidelines for
recruitment and screening of participants, implementation of PEARLS by counselors, data
management, and clinical supervision. The Toolkit is designed to provide background information
prior to training, and to serve as a job aide for PEARLS counselors and other staff to use in
implementing PEARLS.
The training plan is divided into the following sections:

Audience
A description of the staff roles involved in implementing PEARLS and the extent to which
each of these audiences is involved in training

Training Methods
Outline of methods useful for PEARLS counselors

Content and Time Involved for Training
Guidelines regarding the length of time required for a comprehensive PEARLS training, the
content covered during the training, tailoring the PEARLS training for different roles, prerequisites assignments and post-training activities (follow-up and mentoring for newly
trained PEARLS counselors)

Other Training Options
Leveraging existing training opportunities
Audience: Guidelines Regarding Who Should Attend Training
The main audience for the PEARLS training is the PEARLS counselors. The PEARLS counselors
will require the greatest degree and depth of training as the counselors work directly with program
participants, implementing PEARLS in the home setting.
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Appendix D: Implementation and Training Plans
Additional groups that need to be trained, but less intensively and involving fewer hours, include:

An organizational Leader (Administrator)

The PEARLS Manager

Case Managers (who are not also serving as PEARLS Counselors), and

A Data Coordinator
Along with the PEARLS counselor, these key roles are instrumental in the successful
implementation of PEARLS within an agency. In some settings, different individuals take on each
role; in other settings, one person may play more than one, or even all, of these roles.
This document outlines the training required for all roles, as well as training designed to address
specific needs for the PEARLS counselor.
It is recommended that the entire team from an agency attend the in-person training workshop to
reinforce the team aspect of PEARLS implementation. The workshop is organized so that the initial
topics are aimed at all roles and the later topics are focused specifically for the PEARLS counselors.
Training Methods: Outline of Methods Useful for PEARLS Counselors
This section outlines the instructional strategies that will be used to involve the audience in the
training. These methods are designed to help trainees gain the knowledge and skills required for
each role in PEARLS, and to apply their knowledge and skills in both a training setting and on the
job.
To establish and reinforce learning, these methods will be integrated into three phases of training:
preparation, a training workshop, and follow-up activities. Each method reflects one or more of a
number of types of learning objectives in the cognitive domain.
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Appendix D: Implementation and Training Plans
Phase
Instructional Strategy or Method
Type of Learning Objective
Preparation
Review Toolkit
Knowledge
Didactic Lecture, Demonstration,
Observation
Knowledge
Role Play, Scenarios, Practice
Comprehension, Application
Feedback, Peer Feedback, Discussion
Analysis
Supervision
Application, Synthesis
Self-evaluation
Evaluation, Analysis
Monthly Support/Conference Calls
Application, Analysis, Synthesis
Training
Workshop
Follow-up
This plan builds upon methods that have been effective during the PEARLS training workshop to
date, supplementing the previous plan with additional strategies, in particular elements of
preparation and follow-up activities to reinforce the in-person workshop training. These additional
strategies are beneficial not only to the trainee, but also to the trainer. Trainees will now enter the
PEARLS training workshop with familiarity of PEARLS via reading sections of the toolkit, so that
Trainers can focus on building upon existing knowledge. Likewise, training does not end at the
close of the workshop; trainers know that the counselors go back “into the field” with support
available during the follow-up phase.
These methods are organized on a continuum (illustrated below) to build and reinforce the
knowledge, skills, and other learning objectives referenced in the chart above.
Preparation
Reviewing Toolkit
Training Workshop
Follow-up
Lecture,
Role Play,
Trainer and
Ongoing
Self
Monthly
Demo,
Scenarios,
Peer
Clinical
Evaluation
Conference
Observation
Practice
Feedback
Supervision
Calls
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Appendix D: Implementation and Training Plans
Content and Time Involved for Training
This section provides an overview of the content and length of time involved in the comprehensive
PEARLS training, which includes the following three phases:
1. Preparation
2. Training Workshop
3. Follow-up
In the description of each phase, it is noted which audiences that portion of training relates to, and
the specific time required for each group.
Phase I: Preparation – Prior to Training Workshop (Self-Study)
The preparation activities are recommended for all audiences.
Activity
Time Required
Review Implementation Toolkit
~1 to 3.5 hours,
depending on sections
required based on your
role
(review sections specified for your role)
Total Training Time
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1 to 4 hours,
depending on role
Appendix D: Implementation and Training Plans
Phase II: Training Workshop
Following is a model of how the training workshop might be organized in terms of topics and
timeframes. We have found it is helpful for administrators to attend. While they may not be
directly seeing clients, they develop a clearer understanding of the intervention and the
infrastructure required.
Training Day
Day 1
Day 2
Topic
Timeframe
Training Overview
Demonstrations of PEARLS Approach
Issues in Depression and the PEARLS Research Studies
PEARLS Program Components
PEARLS Process Overview
7 Steps in Problem Solving Treatment
Hands-on Skills Practice
Introducing PEARLS to a Participant
Problems vs. Goals vs. Solution
Hands-on Skills Practice
Professional Demonstration / Problem Situations
Review of Day 1 Material
Conducting a Final PEARLS Session
Suicide, self-harm, and abuse prevention procedures
Counselor Monitoring and Supervision
Breakout sessions
- Separate hands-on skills practice groups for people working with
seniors and individuals with epilepsy
- Session for administrators to discuss implementation challenges
and tailoring to individual organization
Recruitment and Screening
Large Group Hands-on Skills Practice to Consolidate Learning
Questions and Wrap-Up, Evaluations
0.50 hour
0.50 hour
0.50 hour
0.50 hour
0.25 hour
0.75 hour
1.00 hour
0.25 hour
0.25 hour
0.75 hour
0.75 hour
0.25 hour
0.25 hour
0.50 hour
0.50 hour
2.00 hour
0.50 hour
1.50 hour
0.50 hour
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Appendix D: Implementation and Training Plans
Phase III: Follow-up – Post Training Activities
The preparation and workshop phases are just the beginning. A key aspect of PEARLS training will
come from ongoing supervision once a counselor begins to implement PEARLS in the “real world”.
The following activities are recommended to ensure that PEARLS Counselors are fully trained as
they work directly with participants.
Activity
Timeframe
Counselor Self-Assessment
Counselors complete a self-assessment form after each PEARLS session,
which helps them to assess and improve their performance from session to
session.
Clinical Supervision
PEARLS counselors have the benefit of meeting with a clinical supervisor
every other week to discuss cases that are particularly challenging and/or
clients who are not improving. This can be one-on-one, or with up to 3
counselors together. In most cases, the supervisor will be a psychiatrist.
For agencies without psychiatry availability, a more experienced counselor
may be able provide this supervision and/or supervision by a psychiatrist
via phone may be arranged.
Monthly Support Conference Calls for PEARLS Counselors
Monthly conference calls amongst PEARLS counselors to discuss
challenges and share ideas and lessons learned. The goals of the call are to
share information and strategies, serve as support, and create a sense of
community amongst the counselors in various settings. One of the trainers
will facilitate this call.
Quarterly Conference Calls for Organization Leaders and PEARLS
Managers
Similar to the calls above for PEARLS counselors, these calls are designed
to create a community and provide a forum for the leadership of PEARLS
to discuss successes, innovative ideas, funding opportunities, challenges,
strategies to address the challenges, and other ideas and lessons learned.
After each session
(about 10 minutes)
Additional suggested activities
Review session audiotapes of other counselors
With participant approval (and assuring compliance with HIPAA
regulations), PEARLS counselors may review audio tapes of other
PEARLS counselors’ sessions, and offer constructive feedback.
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Every other week
(1-2 hours,
depending on if it is
one-on-one or a
group)
Once per month for
Counselors
(1 hour)
Once every three
months for
Organization
Leaders and
PEARLS Managers
(1 hour)
As needed
Appendix D: Implementation and Training Plans
Other Training Options: Leveraging Existing Training Opportunities
Other staff at your organization (who are not PEARLS counselors) play a critical role in making
referrals and/or recruiting PEARLS participants. In addition to attending the training as outlined
above for this audience, there are some existing opportunities that can be leveraged to provide
introductory training about PEARLS for case managers and other agency staff.
State-Mandated Training
The training could be incorporated into training that case managers are already required to attend,
including a New Employee Training and/or Core Training.
Feedback was received from various Washington State AAAs that leveraging these opportunities
would be a welcome way for all case managers to learn about PEARLS, specifically focused on
what they need to know as case managers. In addition, representatives from participating
Washington AAAs suggested that the State Unit on Aging (ADSA) deliver a message about
expectations for case managers to refer people who have depression scores of 4 or more on the PHQ9 in the CARE annual assessment tool to the PEARLS program.
Education of Other Providers
Organizational leaders, PEARLS counselors and/or other experts in late life depression could
educate other organizations and their staff that serve potential PEARLS clients. This education
would focus on the need for, and efficacy of, programs like PEARLS and encourage the case
managers to and appropriately refer their clients. Such experts could attend staff meetings for other
potential referral organizations (e.g., primary care clinics, meals on wheels programs) to provide the
information necessary for the case managers to be able to make referrals to PEARLS.
Additional Options to Consider

It may be possible for a State Unit of Aging to partner with the State Mental Health Division
to incorporate PEARLS into the 100-hour geriatric mental health training requirement.

State Units on Aging may consider supporting the logistical and financial responsibility of
providing PEARLS training to interested Area Agencies on Aging, through close
collaboration with the University of Washington Health Promotion Research Center.

For statewide training of PEARLS, consider contracting with trainers or developing a Trainthe-trainer curriculum.

Over time, develop a peer-based training model.
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Appendix D: Implementation and Training Plans
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