Improving Management of Depression and Suicide Screening for Older Adults Receiving Home Health Care: A Quality Improvement Project

Suicide is a leading cause of death in the United States, with the highest rates in adults 65 and older, 15.3 to 22.4%. Adults (65+ years) are at risk for loneliness, social isolation, and comorbid medical and behavioral health conditions which increase depression and suicide risk. Older adults comprise home health clinicians' largest patient population. Yet, many home health agencies do not have or use continued care protocols for depression and suicidal ideation in older adults. Behavioral health interventions are often at home health clinicians' discretion, leading to inconsistent care practices and poor health outcomes. Local Problem: RiverStone Health provides home healthcare to Billings and Yellowstone County, Montana patients. Yellowstone County reported the highest number of deaths by suicide in older adults (> 65 years). CDC records (2023) report seventy-five older adult deaths by suicide between 2010 and 2020. Furthermore, the age-adjusted suicide rate of older adults in Yellowstone County is 27.35 per 100,000, which is higher than the national average of 15.3- 22.4 for adults ages 65 to 85+ years. RiverStone Health does not have formal treatment protocols or accessible behavioral health resources for older adults screening positive for depression. Methods: The Lean Six Sigma model guided the development of this quality improvement (QI) project, which implemented a protocol for screening and a toolkit of resources for admitting clinicians to use with home health patients. Interventions: RiverStone Home health clinicians completed a pre-intervention survey measuring their comfort and confidence levels working with depressed and suicidal patients and perceived needs for a toolkit. Survey data and feedback guided the development of a resource toolkit and protocol outlining steps to take when managing depressed and suicidal patients. The protocol and toolkit were stored on company-issued iPads. After a ten-week implementation period, clinicians completed a post-survey measuring their post-intervention comfort, confidence, and concerns. Results: During the project implementation period, RiverStone Health admitted 80 patients and identified 12 patients (15%) who screened positive for depression. Each positive screen resulted in a fax or phone call to the patient's primary care provider (PCP) notifying them of elevated PHQ-9 scores. However, none of the faxes or phone calls resulted in subsequent action by the PCP. Twelve RiverStone Health clinicians completed the pre-survey (N=12, 100%), five completed the post-survey (n=5), and two clinicians (40%) did not use the protocol or resource toolkit. The three clinicians (n=3, 60%) who used the toolkit and protocol reported that the PDF toolkit was user-friendly and noted improved comfort and confidence in implementing depression screenings. Conclusion: This QI project's intervention supplemented existing admission paperwork and only required additional steps when patients screened >5 on the PHQ-9. Although post-survey responses were limited, results suggest that the toolkit was effective in improving clinician comfort and confidence in managing depressed home health patients but had no effect on the management of symptoms from PCPs. Future QI projects should focus on screening patients receiving chronic home health care and improving PCP participation in depression management.