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

项目总结 在低收入、不同种族的返乡老年人中，抑郁症和跌倒的发生率明显高于 一般老年人口；然而，现有的护理系统不具备解决以下方面的差距的能力 为这些脆弱的老年人提供心理健康和预防跌倒服务。该计划的长远目标 拟议的研究是为了改善越来越多的低收入人群获得抑郁症治疗和预防跌倒的机会。 收入居家的老年人。具体目标是比较综合远程治疗的临床和成本效益。 由学士级别的业馀顾问/教练提供行为激活(Tele-BA)和预防跌倒(FP)，以 TELE-BA或FP单独和注意控制(AC)。目前和预计的执业临床医生和 部署训练有素的专业人员的成本通常对向老年人提供服务构成了障碍 尤其是低收入家庭的老年人。一种更具可扩展性的选项是利用非专业顾问/教练， 我们最近的临床试验(1R01MD009675)和FP试点研究表明，非专业顾问/教练是AS 作为有执照的临床医生有效。这项研究的参与者将是320名低收入、不同种族的家庭居民 由中环的上门送餐(HDM)计划和其他老龄服务机构提供服务的老年人 德克萨斯州。非专业顾问/教练将在HDM计划中共同安置，以实现无缝转介和护理 协调。在一项四臂、务实的临床试验中，在征得同意之前随机进行(首选的公共卫生 方法)，综合Tele-BA和FP(以下简称为TBF)ARM的参与者将获得5个Tele-BA 会议和4个家庭计划生育会议。那些在Tele-BA或FP单独手臂中的人将收到各自的 干预和4个双月电话登记(助推器)电话，AC部门的人员每周将收到5个电话 电话登记电话，然后是每两个月一次的后续电话。研究假设是：12岁、24岁和36岁 基线数周后，(1)TBF将比单独的Tele-BA或FP更有效，单独的Tele-BA或FP将更有效 比AC更有效地减少抑郁(24项汉密尔顿抑郁症评定量表)、跌倒和 (2)在减少残疾方面，TBF比单独的Tele-BA或FP更有效(WHODAS 2.0) 以及医疗和社会服务的使用；以及(3)TBF将比单独使用Tele-BA或仅使用FP更具成本效益。 成本效益分析(CEA)将基于无抑郁天数、预防跌倒和与健康相关的 按EuroQol-5(EQ-5D)衡量的质量调整寿命年。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观点 社区生活管理局以及医疗保险和医疗补助中心。对公共卫生的重要意义 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 它的目标是对以下两个最常见的残疾加速来源和医疗保健使用进行干预 快速增长、服务不足的人口。(我们交替使用老年人和老年人这两个词 因为后者经常用于老龄化服务。)

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.)