Homecare Agency-Randomized Trial of Web Implementation Strategy for Depression

描述（由申请人提供）：本申请响应PAR 10-038“卫生领域的传播和实施研究”，该倡议侧重于基于证据的干预措施的生产与其在“现实世界”中的使用之间的“差距”。这个问题在像家庭健康这样的组织中更加严重，因为大多数机构都是小型的、分散的、地理上分散的。很少有人能负担得起先进的质量改进。这种情况并不是家庭保健（HH）所独有的，因为许多国家的医疗保健是由资源贫乏的公共和非营利机构提供的。本研究测试了基于网络的实施策略（MHTraining-Net）对抑郁症护理路径的有效性，这是一种基于协作抑郁症护理模式的HH干预。CAREPATH将模型的抑郁护理管理功能整合到HH护士的日常实践中，包括：a.监测抑郁严重程度；b.关于药物和/或心理治疗的咨询；c.药物管理；d。教育;e.围绕自我护理、愉快活动和社会接触设定患者目标。MHTraining-Net采用电子学习模块、网络研讨会、电子邮件/电话咨询和社交网络技术，提供四项实施活动：2.基础设施建设；培训,3。3 .监督/绩效反馈；社会学习。MHTraining-Net对CAREPATH实施的效果将与增强支持条件进行比较。本研究采用机构随机设计，每组60个HH机构。所有HH机构都是CareAnyware公司的客户，该公司提供基于网络的临床管理软件。CAREPATH协议已经编程到该软件中，所有机构都可以访问。该研究将分析约7800名临床显著抑郁症（PHQ-9 bbb15）老年患者的常规收集数据。目的是测试MHTraining-Net在以下方面的有效性：改变实践：提高护士对CAREPATH协议的依从性；和2。改变患者的预后：降低抑郁症的严重程度。试点数据表明，MHTraining-Net是可行的，为卫生保健机构所接受，并对患者护理和临床结果产生积极影响。抑郁症影响超过25%的老年HH患者，大多数未被发现或治疗不当，并导致更差的健康结果和更高的医疗费用。该研究利用技术进步设计了一种实施策略，可以覆盖分散的、地理上分散的机构，并设计了一种研究策略，将机构随机试验的力量与大型、多样化患者群体的普遍性结合起来。鉴于其长期覆盖范围，MHTraining-Net具有显著改善老年HH患者抑郁症护理和减轻该人群抑郁症公共卫生负担的潜力。

DESCRIPTION (provided by applicant): This application responds to PAR 10-038 "Dissemination and Implementation Research in Health", an initiative focused on the "gap" between the production of evidence-based interventions and their use in the "real world". This problem is exacerbated in organizations like Home Health as most agencies are small, decentralized and geographically dispersed. Few can afford advanced quality improvement. This situation is not unique to Home Health (HH) as much the nation's health care is provided by resource-poor public and not-for-profit agencies. This study tests the effectiveness of a web-based implementation strategy (MHTraining-Net) on the Depression CAREPATH, a HH intervention based on the Collaborative Depression Care model. CAREPATH integrates the model's depression care management functions into routine practice of HH nurses, including: a. Monitoring depression severity; b. Consultation about medication and/or psychotherapy treatment; c. Medication management; d. Education; and e. Patient goal setting around self care, pleasurable activities and social contact. MHTraining-Net employs e-learning modules, webinars, email/phone consultation, and social networking technology to deliver four implementation activities: 1. Infrastructure development, 2. Training, 3. Supervision/performance feedback, and 4. Social learning. The effect of MHTraining-Net on implementing CAREPATH will be compared to an Enhanced Support condition. The study uses an agency-randomized design, with 60 HH agencies per arm. All HH agencies are clients of CareAnyware, Inc, a company that provides web-based clinical management software. The CAREPATH protocol is already programmed into this software and accessible to all agencies. The study will analyze routinely collected data from an estimated 7,800 older patients with clinically significant depression (PHQ-9>15). The aims are to test the effectiveness of MHTraining-Net on: 1. Changing Practice: increasing nurse adherence to the CAREPATH protocol; and 2. Changing Patients' Outcomes: reducing severity of depression. Pilot data suggest that MHTraining-Net is feasible, acceptable to HH agencies, and positively affects both patient care and clinical outcomes. Depression affects over 25% of older HH patients, is mostly undetected or poorly treated, and leads to worse health outcomes and higher healthcare costs. The study takes advantage of technological advances to design an implementation strategy that can reach decentralized, geographically dispersed agencies, and a research strategy that couples the power of an agency-randomized trial with the generalizability of a large, diverse patient population. Given its long reach, MHTraining-Net has the potential of significantly improving care for depression in older HH patients and reducing the public health burden of depression in this population.