Integrating Depression Care Management into Medicare Home Health Reduces Risk of 30- and 60-Day Hospitalization: The Depression Care for Patients at Home Cluster-Randomized Trial

Abstract

Objectives: To determine whether a depression care management intervention in Medicare home health recipients decreases risk of hospitalization.

Design: Cluster-randomized trial. Nurse teams were randomized to intervention (12 teams) or enhanced usual care (EUC; 9 teams).

Setting: Six home health agencies from distinct geographic regions. Home health recipients were interviewed at home and over the telephone.

Participants: Individuals aged 65 and older who screened positive for depression on nurse assessments (N = 755) and a subset who consented to interviews (n = 306).

Intervention: The Depression CARE for PATients at Home (CAREPATH) guides nurses in managing depression during routine home visits. Clinical functions include weekly symptom assessment, medication management, care coordination, patient education, and goal setting. Researchers conducted telephone conferences with team supervisors every 2 weeks.

Measurements: Hospitalization while receiving home health services was assessed using data from the home health record. Hospitalization within 30 days of starting home health, regardless of how long recipients received home health services, was assessed using data from the home care record and research assessments.

Results: The relative hazard of being admitted to the hospital directly from home health was 35% lower within 30 days of starting home health care (hazard ratio (HR) = 0.65, P = .01) and 28% lower within 60 days (HR = 0.72, P = .03) for CAREPATH participants than for participants receiving EUC. In participants referred to home health directly from the hospital, the relative hazard of being rehospitalized was approximately 55% lower (HR = 0.45, P = .001) for CAREPATH participants.

Conclusion: Integrating CAREPATH depression care management into routine nursing practice reduces hospitalization and rehospitalization risk in older adults receiving Medicare home health nursing services.

Trial registration: ClinicalTrials.gov NCT01979302.

Keywords: care management; depression; home health; hospitalization.

Figure 1

Nurse Team Randomization and Patient Recruitment ^H1 Eligible patients considered for Hypothesis 1 (H1). Eligible patients received care from nurses randomized to CAREPATH or Enhanced Usual Care but may or may not have participated in detailed research assessments. ^H2 Subset of eligible patients who participated in research interviews and included in analysis of Hypothesis 2 (H2).

Figure 2

Hospitalization among Eligible Medicare Home Health Patients with PHQ2 Score ≥ 3.

Figure 3

Estimated Relative Hazard of Hospitalization for CAREPATH Patients Compared to Enhanced Usual Care Patients Note. aRR: adjusted relative risk from log-binomial generalized linear models; aHR: adjusted hazard ratio from Cox proportional hazards models.