Technology-assisted peer support for recently hospitalized depressed Veterans

Veterans Health Administration, Decatur PA

Investigators

Abstract

Veterans Health Administration (VHA) patients are at high risk for poor outcomes and often receive inadequate care following discharge from an inpatient psychiatric stay for major depression. Despite recent improvements in immediate post-hospital follow-up, there has not been similar improvement in longer-term treatment engagement, nor have hospital readmission rates decreased. Peer support following hospitalization, a recovery-oriented service, has been shown to reduce the likelihood of readmission. Randomized control trial evidence demonstrates peer support is effective for improving symptoms of depression compared to usual care. Peer support services in the VHA are expanding, particularly after President Obama's executive order to hire 800 peer specialists. However, implementation of peer-based services for Veterans recently hospitalized for depression may be impeded by the lack of well-defined programs and roles. Health information technology can help structure peer support in addition to providing many of the elements of evidence-based depression care management. The CarePartner program uses interactive voice response (IVR) telephone technology to conduct standardized symptom assessments, monitor treatment adherence, and support patient self- management. The CarePartner program also provides feedback to a patient's informal caregiver, typically a family member, to enhance the support patients receive from others. This program has been implemented in several VHA and non-VHA clinics with high rates of engagement, and program participants experience improvement in their depression symptoms. In this study we will adapt the CarePartner program by incorporating peer specialists as an alternative to informal caregiver involvement because hospitalized depressed patients often have limited social support networks and because peer specialists may be more effective in impacting severely depressed patients' recovery. We will recruit 20 patients to participate in a single-site single-arm pilot study of the combined peer specialist/CarePartner program. The aims of the study will be to assess the feasibility and acceptability of the combined intervention, to determine preliminary estimates of the program's impact on depression symptoms, recovery-oriented outcomes, and service utilization, and to assess barriers and facilitators to implementation of the program. We will recruit and enroll patients admitted to the acute inpatient psychiatric unit at the VA Ann Arbor Medical Center. Eligible patients will have a diagnosis of major depression and will not have active substance dependence, psychosis, or a cognitive disorder. After discharge patients will receive regular contacts (weekly at first, then at least every other week) from a peer specialist and the CarePartner IVR system for 3 months. We will assess the number of patients who choose to enroll in and complete the program, the number of completed IVR and peer support calls, and patients' satisfaction with the program. Measures of depression symptoms, quality of life, functioning, and recovery will be compared between baseline and 3 months post hospitalization. Medical record data will be used to assess treatment adherence, suicidal behaviors, and repeat hospitalizations. The RE-AIM framework and priority constructs from the consolidated framework for implementation research (CFIR) will guide evaluation of program implementation. Data will include quantitative measures of program activity and qualitative assessments from stakeholder focus groups conducted at early and late stages of implementation. This pilot work will inform the development of a multi-site hybrid implementation/effectiveness study to improve the care delivered to patients after hospitalization for depression.