Partnering With Community-Based Organizations to Improve Collaborative Care for Late-Life Depression

Collaborative care can go a long way toward improving access to care for common mental health problems. This month’s author, Theresa Hoeft, Ph.D., describes how partnerships between clinic-based collaborative care programs and community-based organizations can further enhance depression care for older adults. —Jürgen Unützer, M.D., M.P.H.

Despite recent advances, older adults with depression often do not seek or receive effective treatment. One of the most promising approaches to improving the reach and effectiveness of depression care in older adults is the systematic involvement of community-based organizations (CBOs) or family care. In 2014, the Archstone Foundation launched an initiative known as Care Partners: Bridging Families, Clinics, and Communities to Advance Late-Life Depression Care. It supports partnerships of primary care clinics and CBOs and/or family members as care partners to enhance collaborative care for depression.

Some CBOs offer home visits that, similar to working with family members as care partners, can give providers a more intimate sense of patient needs. These connections can enhance care when community partners with a more complete picture of the patients’ lives in the community are connected with the patients’ providers and health record.

CBOs can also enhance care for depression by increasing the reach of mental health programs through interactions with people where they live and socialize and by increasing connections to community services to address unmet needs. Programs like the PEARLS model of collaborative care were designed to reach older adults in their homes and can help engage patients who may be less likely to engage in care with a primary care provider (PCP). PEARLS providers offer home visits and can enhance connections to primary care for those with PCPs and create linkages to clinics for those without a medical home. Additionally, the relationships between some larger CBOs and other agencies, like Adult Protective Services, can facilitate patients reaching these agencies and needed services. Follow-up with the patient on whether they connected with the referral is also critical. Such follow-up can be designated to a provider in the clinic, but this important step often falls lower on the list of competing priorities and may get more attention from a CBO partner.

When sharing care activities with CBOs or family care partners, you need to establish a clear understanding of the roles for each member of the extended collaborative care team or the family care partner. Outlining these roles can also highlight the value that the CBO or family member brings to the team. These new roles, for example, may offer eyes and ears in the home, enhanced referrals to social services, or improving engagement in care. Also, some CBOs that employ lay health providers (for example, community health workers or peers) may accomplish such goals at a lower overall cost.

Clinics and CBOs face several barriers to collaboration, perhaps most notably separate financing streams, but valuing services offered by each organization is a sound starting place for working together. Clinics and CBOs differ in organizational culture and pace of operations, and they also do not typically have a shared communication infrastructure in place. Establishing communication strategies and necessary access to electronic health records for CBO staff and clinicians often requires strong champions at each organization. Champions can remove barriers to collaboration and convince their organizations that patient needs often cannot be completely met by the health care system alone.

Building bridges to CBOs and family care partners can enhance clinic-based collaborative care when such partnerships are thoughtfully developed. Working with these different partnerships on the Care Partners project and learning with them as they navigate strong working relationships across systems has been a rewarding experience. As a researcher trained in population health, I find it exciting to watch many of these organizations engage patients in care and address social determinants of health as shared goals, challenges that the health care system cannot fully address alone. Several Care Partners partnerships were sprung from these common goals.

For patients with complex needs in particular, having a diverse team with differing strengths in terms of outreach, engagement, rapport building, and connecting patients to needed social services has turned out to be a powerful way to enhance the care of older adults with depression. ■