“We are the sun for our community:” Partnering with community health workers/promotores to adapt, deliver and evaluate a home-based collaborative care model to improve equity in access to quality depression care for older U.S. Latino adults who are underserved

Abstract

BackgroundWhile depression is a leading cause of poor health, less than half of older adults receive adequate care. Inequities in both access and outcomes are even more pronounced for socially disadvantaged older adults. The collaborative care model (CCM) has potential to reduce this burden through community-based organizations (CBOs) who serve these populations. However, CCM has been understudied in diverse cultural and resource-constrained contexts. We evaluated the implementation and effectiveness of PEARLS, a home-based CCM adapted with and for community health workers/promotores (CHWs/Ps).MethodsWe used an instrumental case study design. Our case definition is a community-academic partnership to build CHW/P capacity for evidence-based depression care for older U.S. Latino adults in the Inland Empire region of California (2017–2020). We aimed to understand adaptations to fit local context; acceptability, feasibility, and fidelity; clinical effectiveness; and contextual determinants of implementation success or failure. Data sources included quantitative and qualitative administrative and evaluation data from participants and providers. We used descriptive statistics and paired t-tests to characterize care delivery and evaluate effectiveness post-intervention, and deductive thematic analysis to answer other aims.FindingsThis case study included 152 PEARLS participants and nine data sources (N = 67 documents). The CBO including their CHWs/Ps partnered with the external implementation team made adaptations to PEARLS content, context, and implementation strategies to support CHWs/Ps and older adults. PEARLS was acceptable, feasible and delivered with fidelity. Participants showed significant reductions in depression severity at 5 months (98% clinical response rate [mean (SD), 13.7 (3.9) drop in pre/post PHQ-9; p < 0.001] and received support for 2.6 social needs on average. PEARLS delivery was facilitated by its relative advantage, adaptability, and trialability; the team's collective efficacy, buy-in, alignment with organization mission, and ongoing reflection and evaluation during implementation. Delivery was challenged by weak partnerships with clinics for participant referral, engagement, reimbursement, and sustainability post-grant funding.DiscussionThis case study used existing data to learn how home-based CCM was adapted by and for CHWs/Ps to reduce health inequities in late-life depression and depression care among older Latino immigrants. The CBOs and CHWs/Ps strong trust and rapport, addressing social and health needs alongside depression care, and regular internal and external coaching and consultation, appeared to drive successful implementation and effectiveness.

Urban relatives ameliorate survival disparities for genitourinary cancer in rural patients

“…On the other hand, lower levels of family support for young breast cancer patients was significantly associated with cost‐related lack of access to care 16 . Another study evaluating a collaborative care model to improve social support for disadvantaged patients, found improvement in depression severity when patients received enhanced social support 17 . Our study is the first to specifically evaluate the impact of having an urban relative for patients physically living in rural areas.…”

“… 16 Another study evaluating a collaborative care model to improve social support for disadvantaged patients, found improvement in depression severity when patients received enhanced social support. 17 Our study is the first to specifically evaluate the impact of having an urban relative for patients physically living in rural areas. In the context of existing literature, it is a reasonable presumption that enhanced family support paired with enhanced social resources from urban relatives living physically nearer to cancer centers contributes to improved outcomes for rural patients.…”

Effectiveness of the Program to Encourage Active, Rewarding Lives (PEARLS) to reduce depression: a multi-state evaluation

“…This variability between outcome definitions reinforces the need for careful selection of clinically meaningful improvements by sites delivering PEARLS. Understanding the anticipated number of sessions needed to achieve clinically meaningful improvements can help sites maintain program fidelity (33) to retain PEARLS participants and ensure they receive an adequate intervention dose while reducing wait times for services (23,27,61).…”

“…Previous research has demonstrated the effectiveness of PEARLS to reduce clinically significant depressive symptoms via randomized controlled trials with older adults with minor depression or dysthymia as well as adults with epilepsy and co-cooccurring major depression (24-26). Beyond this efficacy research, implementation research has been conducted to evaluate the public health impact of PEARLS via the RE-AIM Framework (27), studies have identified strategies and adaptations to make PEARLS more effective for and accessible to older adults of color, including linguistically diverse populations (28, 29). Despite the previously documented effectiveness of PEARLS, fewer studies have examined PEARLS participant attributes and program effectiveness in real-world implementations across multiple states or its ability to reduce depression using different clinical criteria including clinical remission and response.…”