OBJECTIVE: Extending collaborative care, a model integrating mental health services into primary care, to include community-based organisations (CBOs) may improve older patient health outcomes by increasing access to care and addressing patients social needs; however, little is known about how CBOs contribute to such partnered depression care. We explored how six primary care clinic and CBO partnerships came together to provide late-life depression care through the Care Partners funded in 2014. DESIGN: 43 key informant interviews and 15 focus groups were conducted with care managers, administrators and primary care providers partnering to provide late-life depression care. Data were coded and analysed iteratively using qualitative thematic analysis. SETTING: Six primary care clinic-CBO sites across California. PARTICIPANTS: Care managers, administrators and primary care providers participated in this study. RESULTS: Three unique contributions of CBOs to depression care in these clinic-CBO partnerships were identified: (1) CBOs added new services that focus on social needs and enhanced depression care; (2) CBOs strengthened core aspects of collaborative care for depression; (3) CBOs provided new avenues for building connections and trust with underserved patients. CONCLUSIONS: CBOs, when partnered with clinics, enhanced both medical and social aspects of depression treatment for older adults. CBOs are well positioned to assist primary care clinics in treating the complex health needs of older adults by providing new and strengthening existing aspects of partnered depression care while building patient trust among culturally diverse populations.

Considerable progress has been made in the treatment of late-life depression over the past 20 years, yet considerable gaps in care remain. Gaps in care are particularly pronounced for older men, certain racial and ethnic minority groups, and those with comorbid medical or mental disorders. We reviewed the peer-reviewed literature and conducted interviews with experts in late-life depression to identify promising directions for effectiveness research to address these gaps in care. We searched the PubMed, PsychInfo, and CINHAL databases between January 1, 1998, through August 31, 2013, using terms related to late-life depression and any of the following: epidemiology, services organization, economics of care, underserved groups including health disparities, impact on caregivers, and interventions. The results of this selective review supplemented by more current recommendations from national experts highlight three priority research areas to improve health services for late-life depression: focusing on the unique needs of the patient through patient-centered care and culturally sensitive care, involving caregivers outside the traditional clinical care team, and involving alternate settings of care. We build on these results to offer five recommendations for future effectiveness research that hold considerable potential to advance intervention and health services development for late-life depression.

BACKGROUND: Collaborative care is an evidence-based program for treating depression in primary care. We sought to expand this model by recruiting clinics interested in incorporating community partners (i.e., community-based organizations (CBO) and/or family members) in the care team. Seven sites implemented evidence-based collaborative care programs with community partners while collecting information on costs of implementing and sustaining programs. METHODS: Sites retrospectively collected data on planning and implementation costs with technical assistance from study researchers. Sites also prospectively collected cost of care activities over a 1-month period once the program was implemented to determine resources needed to sustain programs. Personnel salary costs were adjusted, adding 30% for benefits and 30% for administrative overhead. RESULTS: The programs implemented varied considerably in staffing, involvement of care partners, and allocation of costs. Total planning and implementation costs varied from $39,280 to $60,575. The largest implementation cost category involved workflow development and ranged from $16,325 to $31,375 with the highest costs in this category attributed to the most successful implementation among clinic-CBO programs. Following implementation, cost per patient over the 1-month period ranged from $154 to $544. Ongoing strategic decision-making and administrative costs, which were included in cost of care, ranged from $284 to $2328 for the month. CONCLUSIONS: Sites implemented collaborative care through differing partnerships, staffing, and related costs. Costs to implement and sustain programs developed in partnership are often not collected but are crucial to understanding financial aspects of developing sustainable partnerships. Assessing such costs is feasible and can inform future partnership efforts.

Interest and incentives are increasing around strategies whereby the health care sector can better identify and address patients' social and economic needs in the context of primary care delivery. This interest is likely to accelerate during the economic recession following the OVID-19 pandemic. Yet effective and sustainable strategies for integrating social care practices (eg, patient-facing social risk screening and activities to address identified needs) have not been clearly established. Lessons learned from more than 2 decades of research on behavioral health integration could be applied to efforts to integrate social care into primary care. In this article, we synthesize learnings from primary care and behavioral health care integration, and translate them into organizing principles with the goal of advancing social care integration practices to improve the health of both patients and communities.

Background

National guidelines have called for greater integration of primary care and behavioral health services, with more recent attention to social care and community-based services. Under growing resource constraints healthcare organizations have tended to rely on referrals to external entities to address social care needs. Traditional referral models, however, may not be equipped to provide for the complex needs of older adults with depression. The Care Partners Project was designed to strengthen late-life depression care through integrated partnerships between primary care clinics and community-based organizations. We sought to understand how these integrated partnerships, with shared tasks and accountability across organizations, changed the nature of depression care for older adults.

Methods

We conducted 65 in-depth, semi-structured interviews and six focus groups with service providers involved in the project, including care managers, primary care providers, and psychiatric consultants, and applied inductive and deductive qualitative thematic analysis to develop themes around participants' experiences with the partnered initiative.

Results

We found the partnerships established by the Care Partners Project reshaped late-life depression care in two ways: (1) bidirectional communication across organizations facilitated greater recognition among providers of intersecting medical and social needs associated with late-life depression; and (2) depression care became more coordinated and effective as care teams established or strengthened relationships across organizations.

Conclusions

These findings highlight the ways cross-organizational health and social care partnerships that move beyond traditional referrals can strengthen late-life depression care and enhance organizational capacities.

Partnering across health clinics and community organisations, while worthwhile for improving health and well-being, is challenging and time consuming. Even partnerships that have essential elements for success in place face inevitable challenges. To better understand how cross-organisational partnerships work in practice, this paper examines collaborations between six primary care clinics and community-based organisations in the United States that were part of an initiative to address late-life depression using an enhanced collaborative care model (Archstone Foundation Care Partners Project). As part of an evaluation of the Care Partners Project, 54 key informant interviews and 10 focus groups were conducted from 2015 to 2017. Additionally, more than 80 project-related documents were reviewed. Qualitative thematic analysis was used to code the transcripts and identify prominent themes in the data. Examining clinic and community organisation partnerships in practice highlighted their inherent complexity. The partnerships were fluid and constantly evolving, shaped by a multiplicity of perspectives and values, and vulnerable to unpredictability. Care Partners sites negotiated the complexity of their partnerships drawing upon three main strategies: adaptation (allowing for flexibility and rapid change); integration (providing opportunities for multi-level partnerships within and across organisations) and cultivation (fostering a commitment to the partnership and its value). These strategies provided opportunities for Care Partners collaborators to work with the inherent complexity of partnering. Intentionally acknowledging and embracing such complexity rather than trying to reduce or avoid it, may allow clinic and community collaborators to strengthen and sustain their partnerships.

BACKGROUND: While 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). METHODS: We 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. FINDINGS: This 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 teams 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. DISCUSSION: This 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.