2010 United Way Request for Application
Helping Seniors Be Safe and Healthy at Home Initiative
Community-Based Depression Screening and Intervention
Application Summary: Instructions
To complete this proposal, interested applicants must submit all of the following by 5 p.m. on May 17,
2010:
1. Cover Page
2. Agency Questionnaire
3. Evaluation Participation Agreement – Agencies must agree to comply with evaluation protocols
as part of the pilot process to evaluate the effectiveness of the experience.
All submissions are to be made by attaching the completed documents to an email sent to
jada.shirriel@uwac.org.
Please include your agency name in the footer of each of the UW forms submitted.
If you have questions, contact Jada Shirriel at 412-456-6740.
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Agency Name:
2010 United Way Request for Application
Helping Seniors Be Safe and Healthy at Home Initiative
Community-Based Depression Screening and Intervention
Background
The goal of this depression screening and intervention pilot is to explore the impact of a standard
community-based model for depression screening and intervention for local adoption for frail
and isolated seniors .
The University of Pittsburgh 2007 Needs Assessment Report: Building Community Partnerships to
Reduce Disparities in Depression Recognition and Treatment identifies depression as a major
impediment to wellness for Pittsburgh’s elderly population and provides insight into barriers to
community-based depression screening and treatment through senior serving agencies and community
health centers.
Some of those barriers include:
 General staff issues (recruitment and retention, familiarity with and awareness of mental health
issues, training—particularly training offered to frontline workers, diversity in types of senior
serving agencies and their respective staff competencies, etc.)
 Disparities in mental health screening and treatment services (great variation in the types and
breadth of mental health services offered to seniors in-home—if any, insurance billing issues
related to mental health services, accessibility, participant and family perception of mental health
services, etc.)
 Basic needs of seniors not being met (participants’ basic needs have to be met before they can
engage in health care concerns or mental health care treatments)
 Ethical concerns (privacy, confidentiality and autonomy)
Despite the potential challenges, implementation of a standard community-based model for depression
screening and intervention for frail and isolated seniors will give local senior serving agencies the
opportunity for more meaningful interaction with seniors in their homes, to deter the potentially crippling
effects of depression and add to the quality of life of participants, and to increase organizational capacity
to better understand mental health issues.
Common depression co-morbidities in seniors include:
 Heart disease
 Cerebrovascular disease, stroke
 Parkinson’s disease
 Diabetes
 Pancreatic and some other cancers
 Dementia, including Alzheimer’s disease
 Insomnia
 Pain, including chronic arthritis
These co-morbidities commonly lead to increased need for institutionalization and use of prescription
medications.
United Way of Allegheny County’s Helping Seniors Be Safe and Healthy at Home Initiative currently
focuses on community-based supports such as volunteers to help seniors remain in their homes.
Initiative efforts are informed by the United Way’s Senior Advisory Committee, composed of experts and
leaders in services needed to support frail, isolated older adults. Upon completion of the needs
assessment, the Senior Advisory Committee reviewed three evidence-based depression screening and
intervention programs (HealthyIDEAS, PEARLS and IMPACT) and commissioned a survey of local
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Agency Name:
2010 United Way Request for Application
Helping Seniors Be Safe and Healthy at Home Initiative
Community-Based Depression Screening and Intervention
senior service providers to ascertain local interest in and capacity for such a local depression-screening
and intervention initiative.
The local study, a survey of 42 agencies, confirmed the need for this type of initiative. Over 85% of
responding agencies reported a need to address mental health issues in older adults served. The survey
also revealed that:
 Most of the responding agencies have substantial contact with vulnerable seniors.
 Most agencies have monthly contact with clients and follow these clients for more than 6 months.
 Over two-thirds conduct multidimensional assessments, and three-quarters document
assessments, care plans, and follow-up. Only 39% reported use of computerized assessments).
 Over three-quarters hold regular staff meetings to discuss each client.
 While acknowledging the need, only about one in five of the agencies currently screen for
depression using structured assessments.
Based on the survey results, United Way invited a group of providers that currently offer some formal or
informal depression screening and/or treatment—as well as potential payors (i.e., insurance providers,
county) —to discuss the feasibility of a community-wide pilot. The providers in attendance agreed that
there is a call to action, that the most benefit can be gained from focusing on mild depression and that an
initiative focused on a community-based model for standard implementation should be pursued. All
participants were invited to submit program models that would satisfy the objectives of this project for
consideration as the depression screening and intervention initiative to pilot in Allegheny County. Three
local models were submitted and included along with two evidence-based models for review by all
interested participants. The provider group selected and modified a University of Pittsburgh program
model (model description is attached to this document).
A total of up to eight (8) senior service providers will be selected to implement this one-year pilot.
Program requirements include:
Criteria for selection include a commitment to helping seniors remain in the least restrictive environments
for as long as possible, ability of agency to demonstrate the capacity to successfully participate in this
pilot (including ability to be responsive to staffing and training needs) and ability of the agency to
demonstrate a commitment to meeting the mental health needs of home-bound seniors. This pilot is
targeted for agencies currently serving seniors in their homes with established relationships of longer
than 3 months with these potential participants.
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Agency Name:
2010 United Way Request for Application
Helping Seniors Be Safe and Healthy at Home Initiative
Community-Based Depression Screening and Intervention
Participating organizations will be provided resources to conduct this pilot based on the following
scenarios:
 Scenario 1: Pilot Agency Provides Intervention
In this scenario, the agency applying for funding has an LCSW on staff who can conduct the
PHQ-9 and implement with clients the Problem Solving Treatment (PST) or Brief Behavioral
Training for Insomnia (BBTI). If selected for the pilot, and if selected to use its own LCSW,
reimbursement will be provided at the rate of $350 per series of PST or BBTI (usually six 30minute sessions). This reimbursement figure also accounts for necessary data collection efforts
over the course of the pilot year. This pilot will fund up to 40 interventions per funded agency.
Mental health referral sources will be provided for clients who may not be suitable for this pilot.
 Scenario 2: Outside Contractor Provides Intervention
In this scenario, the agency applying for funding will utilize an outside contractor (LCSW) funded
by United Way to conduct the PHQ-9 and implement with clients the Problem Solving
Treatment (PST) or Brief Behavioral Training for Insomnia (BBTI). If selected for the pilot using a
contracted LCSW, the agency will receive a flat rate of $1,500 to conduct necessary data
collection efforts over the course of the pilot year. This pilot will fund up to 40 interventions per
funded agency.
Mental health referral sources will be provided for clients who may not be suitable for this pilot.
Pilot participants will also be provided 1) program orientation/training, 2) ongoing clinical and project
support, 3) depression screening and data collection tools, 3) support in identifying referral sources, and
4) access to other pilot participants as a learning community. Grant awards will be paid in monthly
installments from July 2010 through June 2011.
Specifically, participating agencies must:






Have appropriate staff participate in all required trainings (pre-program and field supervision)
Conduct screenings as part of assessment/reassessment process (training provided)
Provide the appropriate intervention (training provided, if applicable)
Be dutiful and accurate in data collection and reporting (training provided)
Commit staff needed for direct service delivery, project oversight and data management
Participate in monthly/bi-monthly project (learning community) meetings – to be scheduled after
grantees are selected
Proposals must be submitted by 5 p.m. on May 17, 2010.
United Way will host an interest meeting on Friday, April 30, 2010 at 9:00am at United Way of Allegheny
County, 1250 Penn Avenue (Strip District) for interested organizations to learn more about the training
and implementation of the pilot program as well as what is expected of participants. Programs will be
notified of their selection on June 11, 2010.
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Agency Name:
2010 United Way Request for Application
Helping Seniors Be Safe and Healthy at Home Initiative
Community-Based Depression Screening and Intervention
Cover Sheet:
Helping Seniors be Safe and Healthy at Home Initiative –
Community-Based Depression Screening and Intervention
Cover Page
Agency Name:
Address:
Website:
Executive Director:
Email:
Phone Number:
Primary contact name:
Email:
Phone number:
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Agency Name:
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Budget Information (your current program budget)
Total cost of current program into
which the pilot will be incorporated
Total number of participants
currently served
$
Average cost per participant for
current program
$
Current Annual Agency Budget: $
Fiscal year
Amount of operating surplus
if any
2008
$
$
$
2009
$
$
$
2010
$
$
$
(Actual or Budgeted)
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Amount of operating
deficit if any
Total expenses
Agency Name:
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Evaluation Participation Agreement
The _____________________________________ agrees to comply with all evaluation requirements
Name of Organization
if selected to implement the pilot project. Specific elements of this evaluation will be decided by the
United Way in consultation with the selected cohort sites. An independent evaluator will assess the
success of the program (with input from participating organizations) and give recommendations for
improvement. Participating organizations will not bear the costs associated with implementing the
evaluation components.
I understand that the evaluation information may be shared broadly to inform the replication of the pilot
project in additional sites. I also understand that the dissemination strategy will not include any
identifying information for specific participants.
_______________________________________________
Program Director (or other person responsible for
implementing this pilot)
_______________________
Date
_______________________________________________
Agency Executive Director
_______________________
Date
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Agency Questionnaire
Organization:
Name of person completing this questionnaire:
Title:
1. Do you have a LCSW on staff?
___ Yes
___ No
2. Please indicate your preference of intervention scenario (see page 3):
___ Use our own LCSW (if applicable)
___Use contracted LCSW
3. Please indicate if your organization has the following qualifications:
Yes
No
a. We are a case management care provider
b. We serve most of our participants by phone and home visit
c. We serve most of our participants over a period of at least 3-6 months
d. Most of our participants are able to participate in their own care planning
e. Most of our participants are able to communicate verbally
4. How central to your case management practice is each of the following functions?
Core
function
Secondary
function
Minimal function
/ Not a function
of our practice
a. Refer and link participants in the
community without purchasing those
services
b. Arrange, manage and monitor
purchased services
c. Teach participants skills
d. Provide clinical counseling to
participants and/or caregivers
e. Provide crisis intervention
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5. In the past year, what was the average caseload per case manager for the
program that would implement this depression screening pilot?
6. Do your case managers currently ask questions to determine if a new or continuing
participant may be experiencing depressive symptoms?
___ Yes, this is a part of our standard protocol and is used consistently by case managers
___ It is a part of our standard protocol but is used selectively by case managers
___ No, that is not part of our case management protocol
7. After initial assessment, what is your agency’s policy or standard for the maximum
time between case managers’ contacts with a client—by phone and in-home visits?
Weekly
Monthly
Quarterly
Semiannually
Annually
N/A
In-home visit
(check one)
Phone contact
(check one)
8. Does your agency use any of the following with your participants? (Select all
that apply)
___ General screening questions about depression or mood
___ Standardized scales (e.g., the scale for Instrumental Activities of Daily Living)
___ Standardized depression scales (e.g., Geriatric Depression Scale [GDS], the
Patient Health Questionnaire [PHQ-9], etc.)
8. The following statements describe various organizational-level considerations for
implementing this pilot program. Please indicate the degree of difficulty your
organization would have if you were to participate in this pilot.
1
Very
difficult
2
3
4
5
Not at all
difficult
a. Identify appropriate sources of mental
health care in the community
b. Modify assessment forms to include
structured questions related to
screening for depression symptoms
c. Modify client record keeping to track
mental health referrals and their
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results
1
Very
difficult
2
3
4
5
Not at all
difficult
d. Seek alternative sources of financial
support, if needed, to keep this
community-based depression
screening program running over time
e. Find time for frontline staff to
complete training (a1/2 day seminar)
f. Find time for clinical staff (if
applicable) to complete training (a
day-long seminar and 4 weekly 20minute in-field supervision calls)
g. Include success of this pilot as an
element in performance evaluations
h. Develop or strengthen relationships
with mental health providers to
expand your case management
practice
i.
Allow supervisors time to provide
program oversight
9. Please describe the nature of your interest in this pilot.
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APPENDIX A
Allegheny County Depression Prevention Model
Steven M. Albert, PhD, Charles Reynolds, MD, Jennifer Morse, PhD, Shikha Iyengar, MS, MPH
Department of Behavioral and Community Health Sciences,
Department of Psychiatry, Institute on Aging
University of Pittsburgh
Overview
This model relies on home health aides (or other frontline staff) to assess subthreshold depressive
symptoms as part of their routine assessments, reassessments, and observations of participants using
a very simple screening tool. This short, formal assessment is then passed on to the supervising
RN/LPN or LCSW social worker, who follows up with client contact using a more detailed screening
tool. If subthreshold symptoms are confirmed, the consumer will receive a brief depression
prevention intervention from an on-site agency counselor, who will be trained in problem solving
therapy (PST) and Brief Behavioral Treatment for Insomnia (BBTI). This model builds on the current
UPMC Staying at Home program (Iyengar), a randomized controlled trial of PST to prevent depression
currently in the field (Reynolds, Morse), and experience with the delivery of services to this
population (Albert).
Program Delivery:
Over the next 12 months, agencies funded under this pilot will receive the following:
 Train home health nurses and other staff who provide services to seniors in their homes in
brief formal depression screening. We will use the UPMC I AM HERE program, Interventions
for Assessment of Mental Health in Elders with Resources and Education. This involves a
manual and DVD that home care staff can view on their own and provides complete
instructions for completing the Patient Health Questionnaire-2 (PHQ-2), a brief depression
screening instrument. Results from the PHQ-2 assessments will be reviewed by a social
worker or nurse at the agencies for follow-up. PHQ-2 assessments will be completed every 3
months or whenever participants experience major health events (i.e., after hospitalization).
 Train one social worker or nurse at each agency (or provide a trained “floating” social worker)
in the full Patient Health Questionnaire (PHQ-9), Problem Solving Therapy (PST), and Brief
Behavioral Training for Insomnia (BBTI). Training in the assessment and interventions will
involve a day-long workshop, led by Dr. Jennifer Morse, along with telephone “in-field
supervision” with Dr. Morse over 6 weeks. Participants screening positive on the PHQ-2 will
be contacted by the trained social worker or nurse at the agency to complete the PHQ-9.
Based on this assessment, participants may be referred for depression care (PHQ-9 > 9) or
receive PST (0 < PHQ < 9). If PST is not successful, the social worker or nurse will implement
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BBTI, which has been shown to be effective in depression prevention. Anne Germain, PhD,
developer of BBTI, will lead this component of training. PST and BBTI are each completely
manualized brief interventions with a strong evidence base.
 Provide data system for monitoring depression prevention effort. The data system will record
results from PHQ-2 and PHQ-9 assessments, basic demographic and health indicators for
participants, and ratings from therapists on uptake of therapy. Follow-up PHQ-9 assessments
will be conducted by agency staff not involved with therapy at 6-8 weeks post-therapy and 3,
6, and 12 months.
 Supervise depression prevention effort. Dr. Reynolds will provide clinical oversight. Dr. Albert
will provide research oversight and assure quality of data, study recruitment, and human
subjects protection. Both will contribute effort to the program without compensation as part
of this collaborative effort between United Way of Allegheny County and the University of
Pittsburgh Institute on Aging.
Intervention
PST is similar to the behavioral activation and cognitive-behavioral therapy used in Healthy IDEAS and
PEARLS. A description of PST is attached. One advantage of PST is its effectiveness in reducing distress
in several physical and mental health conditions, including depression. It is also well-suited for mental
health care settings because it can be learned quickly and offered in individual or group formats with
short appointments.
Home health aides or other frontline staff will be trained to screen participants using the Patient
Health Questionnaire-2 (PHQ-2), which records the frequency of lost interest in pleasurable pursuits
and how often participants feel down or hopeless. The completed form will be passed on to a
supervising RN/LPN or LCSW social worker. These staff will follow up with telephone or in-person
contact when participants report either symptom at potentially clinically-significant levels. The
RN/LPN or social worker will query participants on additional depressive symptoms using the PHQ-9
(i.e., insomnia, agitation, suicidality, lack of appetite).
Based on this assessment, the RN/LPN or social worker will refer participants to either (i) no
treatment, (ii) a short course of PST/BBTI with a trained agency staff member, or (iii) direct physician
or psychiatric care. It is also possible for participants to move from step ii to iii, if necessary.
While our initial focus is the most vulnerable seniors in the community, such as participants in the
PDA waiver or OPTIONS program (vulnerable nursing home-eligible seniors living in the community),
the model can be extended to any senior receiving aging services. Given the focus on PST and BBTI,
the model is not suitable for participants with mental illness (e.g., schizophrenia) or severe dementia.
Our experience with PST shows it is appropriate for people with mild cognitive impairment.
Program Outcomes
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The model is designed to reduce depressive symptom burden and the incidence of frank depression.
Secondary outcomes include ratings of PST competencies and referrals to physician or psychiatric
services. Outcomes:

Proportion of participants completing PHQ-2

Proportion of participants screening positive on PHQ-2

Proportion of participants screening positive on PHQ-9

Proportion of participants receiving PST or BBTI

Proportion of participants completing PST or BBTI

Proportion of participants with successful uptake of PST or BBTI, as rated by therapists

Proportion of participants who cross threshold to major depression over 12 months
Limitations
Successful implementation of the program involves cooperation of a number of partners across
agencies and development of clinical skills in home health aides. However, these efforts will help
streamline service delivery and may have the indirect benefit of building credentials of home health
aides and other frontline staff.
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Problem-Solving Treatment: Problem-Solving Treatment (PST-PC) is a brief form of
evidence-based psychotherapy originally developed for use by medical providers in primary
care. PST teaches people how to solve ‘here-and-now’ problems contributing to their
depression and helps increase their self-efficacy. The key factor is not whether the solution is
ultimately successful, but whether the person learns a more positive and structured approach
to coping with problems. Standard PST-PC, delivered according to the manual (Hegel &
Arean, 2003), includes 6-8 individual therapy sessions over a 6-12 week period. PST has
been effective in reducing distress in several physical and mental health conditions (Malouff,
Thorsteinsson, & Schutte, 2007), including depression (see manuals by D'Zurilla & Nezu,
2007; Hegel & Arean, 2003). PST is well-suited to non-mental health care settings because it
can be learned quickly, can be offered in individual or group formats, and has short
appointments. Few published studies have examined the effectiveness of PST as a selective
preventive intervention, but there is initial evidence of a preventive effect (Robinson, et al.,
2008; Rovner, Casten, Hegel, Leiby, & Tasman, 2007). PST has been well-accepted among
minority groups and among older adults as an intervention to treat depression (Arean, Hegel,
Vannoy, Fan, & Unutzer, 2008; Hegel, Barrett, & Oxman, 2000; Schmaling & Hernandez,
2008).
Arean, P., Hegel, M. T., Vannoy, S., Fan, M., & Unutzer, J. (2008). Effectiveness of problemsolving therapy for older, primary care patients with depression: Results from the
IMPACT project. The Gerontologist, 48(3), 311-323.
D'Zurilla, T. J., & Nezu, A. M. (2007). Problem-Solving Therapy: A Positive Approach to
Clinical Intervention. New York, NY: Springer Publishing Company.
Hegel, M. T., & Arean, P. (2003). Problem-solving treatment for primary care: A treatment
manual for Project IMPACT: Dartmoth Univesity.
Hegel, M. T., Barrett, J. E., & Oxman, T. E. (2000). Training therapists in problem-solving
threatment of depressive disorders in primary care: Lessons learned from the
"Treatment Effectiveness Project". Familys, Systems, & Health, 18(4), 423-435.
Malouff, J. M., Thorsteinsson, E. B., & Schutte, N. S. (2007). The efficacy of problem solving
therapy in reducing mental and physical health problems: A meta-analysis. Clinical
Psychology Review, 27, 46-57.
Robinson, R. G., Jorge, R. E., Moser, D. J., Acion, L., Solodkin, A., Small, S. L., et al. (2008).
Escitalopram and problem-solving therapy for prevention of poststroke depression: A
randomized controlled trial. Journal of the American Medical Association, 299(20),
2391-2400.
Rovner, B. W., Casten, R. J., Hegel, M. T., Leiby, B. E., & Tasman, W. S. (2007). Preventing
depression in real age-related macular degeneration. Archives of General Psychiatry,
64(8), 886-892.
Schmaling, K. B., & Hernandez, D. V. (2008). Problem-solving treatment for depression
among Mexican Americans in primary care. Journal of Health Care for the Poor and
Underserved, 19, 466-477.
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