Integrated Tele-Behavioral Activation and Fall Prevention for Low-income Homebound Older Adults with Depression

项目摘要 抑郁和福尔斯在低收入、种族多样化的居家老年人中明显高于在老年人中。 然而，现有的护理系统没有能力解决老年人中的不平等问题。 为这些脆弱的老年人提供心理健康和预防跌倒服务。的长期目标 拟议的研究是为了改善越来越多的低收入者获得抑郁症治疗和预防跌倒的机会， 有收入的居家老人。具体目标是比较综合远程医疗的临床和成本效益， 提供行为激活（远程BA）和跌倒预防（FP）由学士级外行顾问/教练， Tele-BA或FP单独和注意力控制（AC）。目前和预计的有执照的临床医生短缺， 部署训练有素的专业人员的成本对向老年人提供服务构成了障碍 尤其是低收入的居家老人。一个更具可扩展性的选择是利用外行顾问/教练， 我们最近的临床试验（1 R 01 MD 009675）和FP试点研究表明，外行辅导员/教练是 有效的临床医生。这项研究的参与者将是320名低收入，种族多样化的家庭 在中环由上门送餐（HDM）计划和其他老年服务机构提供服务的老年人 德克萨斯非专业顾问/教练将在HDM计划中共处一处，以实现无缝转诊和护理 协同在一项4组、务实的临床试验中，在知情同意前进行随机化（首选公共卫生 方法），集成Tele-BA和FP（以下简称TBF）组的参与者将获得5个Tele-BA 4次家庭FP会议。那些在电信BA或FP单独武器将收到各自的 干预和4个双月一次的电话登记（助推器）呼叫，AC组将每周接受5次 电话报到，随后每两个月打4次后续电话。研究假设：在12、24和36岁时 基线后7周，（1）TBF将比单独使用Tele-BA或FP更有效，并且单独使用Tele-BA或FP 比AC更有效地减少抑郁症（24项汉密尔顿抑郁症评定量表），福尔斯，和 跌倒损伤;（2）TBF比单独使用Tele-BA或单独使用FP在减少残疾方面更有效（WHODAS 2.0） 以及医疗保健和社会服务的使用;以及（3）TBF将比单独的Tele-BA或单独的FP更具成本效益。 成本效益分析（CEA）将基于无抑郁天数、预防福尔斯跌倒和健康相关 通过EuroQol-5（EQ-5D）测量的质量调整生命年。我们还将进行预算影响分析（BIA） 相对于Tele-BA或FP的TBF。CEA和BIA都将采用混合公共计划的视角， 社区生活管理局和医疗保险和医疗补助中心。公共卫生意义 这项研究将为现实世界采用干预交付模式提供所需的经验数据 该计划的目标是干预两个最常见的残疾加速和医疗保健使用来源， 人口迅速增长但服务不足(We老年人和老年人可以互换使用 因为后者经常用于老龄服务。）

PROJECT SUMMARY Depression and falls are significantly higher in low-income, racially diverse homebound seniors than in the general older-adult population; however, the existing systems of care are not equipped to address disparities in mental health and fall prevention services for these vulnerable older adults. The long-term objective of the proposed study is to improve access to depression treatment and fall prevention for growing numbers of low- income homebound seniors. Specific aims are to compare clinical and cost effectiveness of integrated tele- delivered behavioral activation (Tele-BA) and fall prevention (FP) by bachelor’s-level lay counselors/coaches to Tele-BA or FP alone and attention control (AC). The current and projected shortages of licensed clinicians and the costs of deploying highly trained professionals pose barriers to providing services to older adults in general and low-income homebound seniors in particular. A more scalable option is to utilize lay counselors/coaches, and our recent clinical trial (1R01MD009675) and a FP pilot study show that lay counselors/coaches are as effective as licensed clinicians. The study participants will be 320 low-income, racially diverse homebound seniors who are served by a home-delivered meal (HDM) program and other aging-service agencies in Central Texas. The lay counselors/coaches will be co-located in the HDM program for seamless referral and care coordination. In a 4-arm, pragmatic clinical trial with randomization prior to consent (a preferred public health approach), the participants in the integrated Tele-BA and FP (TBF hereafter) arm will receive 5 Tele-BA sessions and 4 in-home FP sessions. Those in the Tele-BA or FP alone arms will receive the respective intervention and 4 bimonthly telephone check-in (booster) calls, and those in the AC arm will receive 5 weekly telephone check-in calls followed by 4 bimonthly follow-up calls. Study hypotheses are: At 12, 24, and 36 weeks after baseline, (1) TBF will be more effective than Tele-BA or FP alone, and Tele-BA or FP alone will be more effective than AC in reducing depression (the 24-item Hamilton Rating Scale for Depression), falls, and fall injuries; (2) TBF than Tele-BA alone or FP alone will be more effective in reducing disability (WHODAS 2.0) and healthcare and social service use; and (3) TBF will be more cost effective than Tele-BA alone or FP alone. Cost-effectiveness analysis (CEA) will be based on depression free days, prevented falls, and health-related quality adjusted life-year measured by EuroQol-5 (EQ-5D). We will also conduct budget impact analysis (BIA) of TBF relative to Tele-BA or FP. Both CEA and BIA will employ a hybrid public program perspective of the Administration for Community Living and the Centers for Medicare and Medicaid. Public health significance of this study is that it will provide empirical data needed for real-world adoption of an intervention delivery model that targets to intervene for the two most frequent sources of disability acceleration and healthcare use among a rapidly growing, underserved population. (We use the terms older adults and seniors interchangeably because the latter term is frequently used in aging services.)