Running head: DEPRESSION CARE MANAGEMENT

A Depression Care Management Intervention for Home Health Nurses
Argie Jamaica Rivera MAN, BSN, RN
Arizona State University, Arizona

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Abstract

Purpose: To examine the implementation of a web-based depression care management training
program to increase home health nurses’ knowledge and attitudes regarding depression.
Background and Significance: The Centers for Disease Control and Prevention reported in 2015
that the incidence of major depression in elderly receiving home health service rose to 13.5%
compared to less than 5% with those not receiving care in the community.
Materials and Methods: An intervention program was offered to a convenience sample of home
health nurses caring for elderly in the community. The Depression CARE for Patients AT Home
(depression CAREPATH), which is an evidenced-based online training program consisting of
didactic resources about depression screening and depression care management and e-learning
modules. Participants were given a pre and post survey to assess their knowledge of the
material. Additionally demographic information was obtained via self-report.
Results: A total of 8 out of 18 home health nurses participated in the study. All were females;
13% Caucasian and 88% were Asian. There’s an average of 37 years old (SD 14.7, range 23-58)
and had 3 years of experience (SD 2.07, range <1-6). The mean depression CAREPATH
knowledge total pre-test score was 15 (SD 1.85, range 13-18), while the mean total post-test
score was 18.13 (SD 0.99, range 17-19). There was a difference in the depression knowledge
test scores at baseline. All the participants obtained a passing score for the post-test (80%). The
mean R-DAQ total pre-test score was 71 (SD 13.37, range 53-71) and mean total post-test score
was 68, (SD 3.48, range 62-70). The professional confidence in depression attitude indicated
agreement post intervention, except with the feeling comfortable in working with physical illness
than mental illness (pre intervention 62.5%, post intervention 100%). Participants agreed that
home health nurses are well placed and more confident in assisting patients with depression (pre

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intervention 75%, post intervention 100%). In addition, participants felt more confident in
assessing suicide risk post intervention in patient s presenting with depression. Based from
Wilcoxon Signed-ranks test, there was a statistical difference, z = -2.536, p= .01, between the
depression knowledge pre and post-test scores, which indicates that there is an increase in
depression knowledge after the intervention. However, there was no significant difference, z = .846, p = .397 between the depression attitude, which indicate that there is no change in
depression attitude after the intervention.
Conclusion: For this sample depression knowledge was increased post intervention, however,
increase in knowledge did not significantly alter the depression attitude. Further study in a larger
more diverse sample is needed for this intervention.
Keywords: Depression care management, depression knowledge, depression attitude, depression,
elderly, home health nurses.

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Depression Care for Home Health Nurses
The shift in caring for the elderly in need for nursing services from acute inpatient
settings to in home health care has validated the need for the home health nurse (De Vliegher et
al., 2014). However, not all home health nurses are well trained to address the increasing
complexity of managing depression among homebound patients (Brody & Groce-Wollord,
2013). Thus, the Community Preventative Services Task Force (2014) suggested the adaptation
of a home-based depression care management intervention and suggests this intervention should
involve an active screening for depression, measurement based outcomes, trained depression
care managers, case management, patient education, and a supervising psychiatrist. The active
screening protocol focuses on who requires the depression care management (DCM) and is
indicated for those with depressive symptoms with or without a diagnosis or use of an
antidepressant. However, there is no standardized DCM policy and procedure for home health
agencies to follow and implement (Liebel & Powers, 2015).
The Depression CARE for Patients AT Home (depression CAREPATH) is an evidencedbased online training program for generalist home health care nurses, physical therapists, and
other health care professionals in a home health setting, which consists of didactic resources
about depression screening and depression care management e-learning module (Bruce et al,
2011; Liebel & Powers, 2015). The depression CAREPATH protocol assists and guides home
health nurses in assessing depression during home visits and reporting pertinent findings to
physicians; in coordinating care with physicians and specialists for further comprehensive
assessment, in diagnosing and treatment; in antidepressant medication management; and in
evaluating plan of care.

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Background and Significance

Elderly
The goal of the Healthy People 2020 (2014) is to promote mental health and prevent
mental illness by providing adequate mental health services, specifically to address the leading
health indicator of reducing the suicide rate. Depression is a significant cause of disability and
most commonly associated with suicide, as 50% of patients who commit suicide are depressed.
This suggests that one elderly patient commits suicide every 80 minutes (AAS, 2014; WHO,
2012). Fifteen percent of elderly suffers from behavioral health problems, which is linked to
decreased adherence to treatment, quality of life, and functioning (SAMHSA/AoA, 2013).
Likewise, significant life changes, history of depression, lack of leisure activities aggravate the
depressive symptoms in elderly patients (Magnil, Janmarker, Gunnarsson, & Björkelund, 2013).
To address these concerns the Centers for Medicare and Medicaid Services (2015)
included the PHQ-2 in the OASIS-C, which is a process measure to evaluate how home health
agencies utilized evidenced-based care. The home health quality measures specifically for
depression, measures the percentage of patients being screened for depression, physician-ordered
plan of care, which includes intervention for referral, medication and monitoring (CMS, 2014).
Results from these screens can identify patients who are depressed and a plan of care can be
initiated.
Depression Care Management
Depression was reported as the fourth leading contributor to the global burden of mental
illness in 2000, and is projected to reach second place in the ranking by the year 2020 (WHO
2012). Bruce et al. (2011) elaborated that the Depression Care for Patients At Home (Depression
CAREPATH) protocol could be one tool that can be used to address the burden of depression.

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The protocol includes the active screening and DCM protocols. Initially, the screening protocol
focuses on which patient would require the DCM and is indicated for those with depressive
symptoms with or without a diagnosis or antidepressant. For example, patients with positive
PHQ-2, but with a score of less than 10 on PHQ-9 are considered to be mildly depressed. If this
is identified the suggested intervention includes health education and monitoring the PHQ-9
score weekly for 2 weeks to identify if the condition continues to worsen. For patients with a
PHQ-2 score of 2 or less, treatment recommendation is to do weekly reassessment only to assess
for change for 2 weeks.
Bao et al. (2015) conducted a qualitative study to assess the gap between actual and best
depression care practices in home health care and the barriers in addressing gaps. Between
February to November 2012, 20 nurses and administrators from five home health agencies in
five states in the Northeast, Midwest and South United States were recruited. The semistructured interview guide consisted of domains and depression care practices before the
intervention. Findings showed that all five key areas, which include screening, assessment, case
coordination, antidepressant management, patient education, and goal setting, are within the
current function of home health nurses. However, results indicated the participants demonstrated
low self-efficacy and stigma with depression care, lack of knowledge about best practices,
insufficient medication management and ineffective interdisciplinary care. In addition, the
importance of primary care providers in the quality improvement of depression management in
home health care was identified (Bao et al., 2015).
Home Health Nurse
De Vliegher et al. (2014) conducted a systematic review and noted reasons that identify
the underrepresentation of the home health nurses’ technical skills. These include lack of

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professional gold standards and questionable validity of tools for measuring the home health
nurses’ activities, lack of standardized definition of home health nurse’s function, and diversity
of financial and reimbursement systems. Although there is a concern with reimbursement from
Medicare, there are various approaches to address this matter, which includes the DCS-type
interventions within the home health coverage, to contract Medicare Part B- qualified providers,
to pay directly to contract agents, and to provide home health care to an outpatient agencies
(Cabin, 2010).
A qualitative descriptive study conducted by Liebel & Powers (2015) shows that home
health nurses are confident in proving quality care to patients with disabilities, but have mixed
views about integrating depression care in daily practice. Mitchell & Kakkadasam (2011)
conducted a meta-analysis to identify the clinical accuracy of nurses in identifying depression in
primary, secondary and nursing homes. Result shows that only 26.3% of community health
nurses correctly identified people with depression, while 94.8% were correctly identified as nondepressed. Although, primary care nurses have higher rate of detecting depression, the rates of
misclassification cannot be understated. Thomson, Lang, & Annells (2008) performed a
systematic review of the effectiveness of in-home community nurse led interventions for the
mental health of older persons. Findings suggest that home health nurses are required to utilize a
standardized validated assessment tool to evaluate the effectiveness of in-home community nurse
led interventions as well as for more accurate detection of depression. Both studies emphasized
the importance of training and utilizing standardized validated assessment tools in enhancing the
quality of nursing patient care by accurately screening and detecting depression among older
adults.
Advanced clinical training in the DCM is essential for home health nurses to adequately

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address homebound patients. Delaney et al (2011), found out that there is an increase in selfefficacy and attitude in providing care for depressed elderly post depression program. To further
address the study’s objectives, a pre and post-test design, appraisal of the self- efficacy, and selfreported attitude were utilized to evaluate the effectiveness of the Phase I program development
of the depression CAREPATH program (Delaney et al., 2011). Aside from integrating new
model of training and education for home heath agencies, the therapeutic nurse-patient
relationship needs to be utilized to sustain more effective health reforms (Liebel & Powers,
2015). This article coincides with the study completed by Flojt, Le Hir, and Rosengren (2014),
which emphasize the importance of learning activities and collaboration, thus influences
patient’s safety.
As a whole, evidence found regarding this topic requires further research studies that
focus on depression care management, home health nurses, and elderly population.
Internal Evidence
In a home health agency in Las Vegas, Nevada, that provides home health services to 18
years old and above patients, 95% have medical/ surgical concerns, which are either referred by
a hospitalist or primary care provider for skilled nursing, physical or occupational therapy
services. These patients are deemed to be homebound and require taxing effort to leave home
unassisted. These patients are at risk to suffer from anxiety and depression due to medical and
behavioral comorbidities and multiple life stressors. In addition, the home health agency
provides psychiatric skilled nursing care to 5% of the patient population, who have been
evaluated and deemed stable to live at home.
Patients who feel depressed and hopeless, either as a medical co-morbidity or psychiatric
illness are being referred to a medical social worker for further assessment. This referral may

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initially be sent from the field home health nurse to the RN case manager assigned to the case. If
pre-determined criteria are met, a psychiatric consult will be initiated and coordination of care
will be reported to the director of nursing (DON). Generally it takes 3 to 4 weeks to schedule an
appointment for an initial psychiatric evaluation. In this home health agency, not all home health
nurses are familiar with care of the mentally ill which limits their ability to care for these
patients. This review of the background and significance of the problem and initial search led to
the clinically relevant PICOT question; “In home health nurses (P), how does a web-based
depression care management training program, specifically the depression CAREPATH (I)
compared to treatment as usual (C) affects knowledge and attitude towards depression?
Evidence Synthesis
Search Strategy
A database search was conducted using the following databases: Cumulative
Index to Nursing and Allied Health Literature (CINAHL), Psychology Information (PsycINFO),
and PubMed Ovid MEDLINE. The three keywords for the exhaustive research are home health
nurse (HHN), depression care management (DCM), and elderly (E). For each keyword, the
symbol “()” was utilized to include synonym words. This process was conducted throughout the
search. For HHN keyword, home health nursing (HHNg) and home health agency nurse
(HHAN) were included. Synonyms for DCM keyword included depression care program (DCP)
and depression care (DC). Lastly, old age (OA), and aged population (AP) are included in the E
keyword.
Index terms used for search in EBSCOhost database included home health nurse (HHN),
depression care management (DCM), and elderly (E). Limits applied included English language,
and dates from 2005 to 2016. Searched were conducted combining HHN, DCM, and E yielded 3

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results. Both HHN and DCM combined yielded 6 results and combining DCM and E yielded 106
studies (Appendix A1).
The PsychINFO database search was performed with the following index terms: home
health nurses (HHN), depression care management (DCM), and elderly (E). Limits included date
from 2005 to 2016 with record, methodology, and supplemental data selected for all. Searches
were conducted combining HHN, DCM, and E yielded 47 studies. Manual reviews of yield
studies were completed for relevance to research question (Appendix B1).
A PubMed database advanced search was performed with the following terms: home
health nurses (HHN), depression care management (DCM), and elderly (E). Limit applied
includes studies published in the last 5 years. Combining HHN, DCM, and E yielded 59 studies.
Manual review of yield studies was completed for relevance to research question (Appendix B2).
After an extensive database research, ten studies have been chosen for inclusion. One hundred
nine studies were reviewed for the literature review, however several studies were removed due
to: insufficient sample size, non-relevant variables and interventions, inadequate and weak
research design and methodology, poor documentation, and impertinent results. The ten studies
included in the literature review met the inclusion criteria for this study and were relevant to the
PICO question. One study each research study was reviewed; data were extracted, and organized
in a synthesis tables for comparison and examination (Appendix E &F).
Critical Appraisal and Synthesis of Evidence
For this research study, ten studies have been chosen for inclusion; all studies were
evaluated utilizing the rapid critical appraisal tool and are illustrated in the evidence tables for
analysis of data (Appendix F). The two SRs are level I evidence, two RCTs are level II evidence,
the 1 quasi-experimental study is a level III evidence, the two cohort studies are level IV

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evidence, one systematic review of descriptive and qualitative studies is level V evidence, and
two descriptive studies are level VI evidence. Most of the studies were of high quality noting the
standard deviation (SD), level of significance (p), and effect size (ES). High volume of studies
with large sample sizes was included in the SR and SR with MTA studies (Appendix E). All
studies required depression as diagnosis, and home health or community as target setting.
All studies excluded cognitively impaired elderly, severely mentally impaired. Seven out
of ten studies implemented a depression management intervention, which differs with mode of
delivery, focused competencies, and key areas to address (Figure E). Few of the research studies
stated a theoretical framework (Appendix E). These showed the transferability and feasibility of
implementation. Validity and reliability of evidence is assumed by utilizing standardized
measuring tools for outcome measures. Nine out of the ten studies identified outcome measures,
while one study discussed the lack of valid instrument (Appendix E).
A moderate degree of homogeneity was identified among the research studies in terms of
population demographics. Majority of the participants were between the ages 47 to 80 and most
were female (Appendix F). Ages 60 and above was not frequently represented (Appendix F).
This may affect the transferability as the age range of the elderly population is between 60 years
and above. Also, some of the studies were conducted internationally. However, the strict
exclusion criteria address this weakness (Appendix E).
Conclusion about Evidence
DCM demonstrated improvement in patient’s outcomes. Although, not every study was
able to show statistically significant outcomes, and there are various depression management
program models, all research studies showed positive development toward addressing depression
in a home health setting. Depression management interventions are feasible, reliable, sustainable,

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and may be implemented by home health nurses. A multifactorial evidenced based DCM, which
includes standardized protocol, validated tools, nurse education for implementation, and
collaborative care has the ability to detect depression symptoms, provide adequate intervention,
and adequate referral.
Project Purpose
The purpose of this evidenced-based project is to examine the implementation of
Depression CAREPATH, a web-based depression care management-training program in
increasing the home health nurses’ knowledge and attitude toward depression.
Evidenced-Based Practice Model and Its Application
The Stetler Model of Research Utilization is an evidenced-based model that examines the
application of evidence to initiate organizational change, and utilizing research in critical
thinking and decision making in clinical practice (NCCMT, 2010). This model includes a fivephase process (Stetler, 2001), and its applicability to this evidenced-based project will be
discussed in this section.
Phase I: Preparation – Purpose, content & sources of research evidence. The PICO
format organizes the pertinent variables in the study. Initial research studies were gathered,
while refining the PICO question yielded little relevant results. Internal evidences from a home
health agency was considered and explored.
Phase II: Validation – Credibility of findings, and potential for qualifiers of
applications. In this phase, extensive database research was conducted and yielded one hundred
nine studies, which were reviewed based on the inclusion and exclusion criteria for the literature
review.

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Phase III: Comparative evaluation/decision making – Synthesis and decision. Based
from the exhaustive literature review, the depression care management program demonstrated
improvement in patient’s outcomes. All research studies showed positive development toward
addressing depression in a home health setting. There are many potential obstacles and
challenges that may be encountered in implementing this plan. Obstacles have been identified
including obtaining approval for the project, acceptance of the project by the home health
agency, data collection, analysis, and utilization of evidence in actual practice. Challenges
include recruitment of participants and active participation, short-lived benefit of intervention,
and resistance to change.
Phase IV: Application – Action for change. At program onset, the goal was to recruit
home health nurses and to schedule a specific date for the study implementation. The depression
CAREPATH is the intervention in this study (Appendix G).
Phase V: Evaluation. A pre/post test research design was employed, which included the
participants’ demographic profile, Revised Depression Attitude Questionnaire (R-DAQ), and the
Depression CAREPATH questionnaire.
Theoretical framework
The conceptual framework for this research study was the Chronic Care Model (CCM).
This model was chosen as it focuses on disease management and quality improvement. The
healthcare system, as the barrier is the theoretical underpinning of CCM, thus CCM serves as an
evidenced-based guideline and synthesis for clinical practice (Holm & Severinsson, 2012). The
CCM consists of six components: community resources and policy; the health system and the
organization of health care; self-management support; delivery system design; decision support;
and clinical information systems (Wagner et al., 2001). To further explore the six components of

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the CCM, and how each component intertwined was further explained (Appendix H). The
depression care management program focuses on integrating behavioral to medical care, which
will improve future partnership with local home health agencies and to develop health policy
reforms. This program intervention will improve the provision of quality patient care in the
community.
Planned Outcomes and Link to Conceptual Model
Home health nurses were the participants in this study. The planned outcomes that were
measured are the home health nurses’ knowledge and attitude towards depression, with both the
Revised Depression Attitude Questionnaire (R-DAQ) and Depression CAREPATH
questionnaire. These outcomes are linked to the conceptual model, as having a well-trained
home health nurses and clinical team are integral in improving and sustaining quality measures.
Since, previous research studies have concluded a positive outcomes of utilizing depression care
management, the ultimate goal of this study was to increase the depression knowledge and
attitude of home health nurses.
Methods
Human Subject Protection
Privacy and confidentiality. During the study implementation, the privacy and
confidentiality rights were discussed. A unique code number was assigned using a predetermined formula to protect the identity of the participant and was used for data collection.
The primary researcher and mentor had access to the data. During data collection, the data from
the questionnaires were collated and tabulated electronically. The identifier and data were
separated, and the questionnaires were shredded for HIPAA regulation compliance.
Consent process. Written consents were obtained prior to the program implementation.

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Participants were instructed to sign a consent stating the purpose, significance, and program
outline. Participants were provided enough time to read the participation letter and to decide if
they want to participate. The study inclusion criteria include more than 6 months of clinical
experience in a home health setting and willingness to participate. Exclusion criteria include
intake coordinators and office managers, who do not provide direct home health care.
Description of Population and Setting
This study was conducted on a convenience sample of 18 home health nurses, who
worked at a home health agency in the Southwest, who met the inclusion criteria. These were
verified with the agency's intake coordinator, HR personnel, and DON.
Project Description & Recruitment
Prior to implementation of the program eligible staff were recruited via an introductory
text and placement of an informational flyers on staff bulletin boards. Reminders via text
messaging were sent 2 weeks and one day prior to intervention. The program was conducted at a
time determined to be agreeable to the agency, convenient for participants, and the home health
care agency office. Participants were not compensated for their participation
Data Collection
The initial data collection included the demographic profile of home health nurses: age,
gender, race, and years of experience in a home health setting. The home health nurses’ attitude
toward depression and depression knowledge were assessed by utilizing the R-DAQ and
Depression CAREPATH questionnaire respectively. As mentioned in the consent process
section, the study inclusion criteria included more than 6 months of clinical experience in a home
health setting, nurses who provide direct patient care, and willingness to participate. There were
24 home health nurses in the home health agency. Six out of 24 home health nurses, were

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excluded due to inactive status, on vacation and maternity leave, and less than 6 months of
experience. Out of the 18 home health nurses, who met the criteria, only 8 participants
completed the intervention due to refusal to participate and conflict with work schedule. These
were verified with the agency's intake coordinator, HR personnel, and Director of Nursing
(DON).
Instrument
Depression attitude. The R-DAQ is a 22-item scale, rated on 5-point Liker scale from 1
‘totally disagree to 5 ‘I totally agree, which focuses on the healthcare workforce in evaluating
their attitude towards depression (Haddad et al., 2015). The 22-item attitude statements note
participants level of agreement, while combining agree and strongly agree, and also includes
items that are reversed for summary scale scoring, but are not scored reversely in this project.
Haddad et al (2015) conducted psychometric testing and found good internal consistency (a =
0.84), satisfactory test-retest reliability correlation coefficient of 0.62 (95% C.I. 0.37 to 0.78).
The tool includes three sub-scales namely professional confidence, therapeutic
optimism/pessimism, and a generalist perspective (Haddad et al., 2015).
Depression knowledge. A 20-item questionnaire, provided by the Depression
CAREPATH was utilized to assess and evaluate the participants’ knowledge. This post-test is
included in the e-learning module of the depression CAREPATH program, and the questions are
directly related to the program. Each questions in the 20- items depression CAREPATH was
worth 1 point. A grade of 80% or 16 out of 20 correct answers are needed to pass the course and
participants can take the final test twice.
Data Analysis
All data were analyzed using Statistical Package for the Social Sciences (SPSS v.

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Descriptive statistics of the demographics, knowledge and attitude towards depression indicated
with standard deviation, mean, number, and percentage as appropriate.
Data Outcomes
Interpretation of Results
Demographics. In total, 8 out of 18 home health nurses completed the study
intervention, with a response rate of 44.4%. All were females 13% Caucasian and 88% were
Asian. There’s an average of 37 years old (SD 14.7, range 23-58) and had 3 years of experience
(SD 2.07, range <1-6).
Descriptive measures. An overview of the knowledge towards depression of home
health nurses can be found in Appendix J Table J1. The mean depression CAREPATH
knowledge total pre-test score was 15 (SD 1.85, range 13-18), while the mean total post-test
score was 18.13 (SD 0.99, range 17-19). There was a difference in the depression knowledge
test scores at baseline. All the participants obtained a passing score for the post-test (80%).
An overview of the attitude towards depression of home health nurses can be found in
Appendix J Table J2. The mean R-DAQ total pre-test score was 71 (SD 13.37, range 53-71) and
mean total post-test score was 68, (SD 3.48, range 62-70). The median score for the RDAQ total
pre-test score was 77, which indicates that 50% score fair either below or above 77. The median
score for the RDAQ total post-test score was 70, which indicates that 50% score fair either below
or above 70.
The professional confidence in depression care indicated agreement post intervention,
except with the feeling comfortable in working with physical illness than mental illness (pre
intervention 62.5%, post intervention 100%). Participants agreed that home health nurses are
well placed and more confident in assisting patients with depression (pre intervention 75%, post

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intervention 100%). In addition, participants felt more confident in assessing suicide risk post
intervention in patient s presenting with depression. Although there is a high agreement in terms
of professional confidence, there is a need to assess the factors related to work setting
preferences before implementing a depression care management program (Appendix K).
In terms of the therapeutic optimism/pessimism about depression views, home health
nurses considered the nature of depression and depression management as optimistic post
intervention. There’s a high improvement in how participants considered depression to be
related to poor stamina (Pre-intervention 75%, Post intervention 12.5%). However, 75% of the
participants considered lack of self-discipline and will power as the main cause of depression pre
and post intervention. The generalist perspective about depression showed a high agreement
both the pre and post intervention (Appendix K).
Non-parametric tests.
For the depression knowledge, A Wilcoxon Signed-Ranks Test indicated that the total
post score was statistically significant higher than the total pre-test scores z = -2.536, p = .011.
The results indicate that there is an increase in depression knowledge after the intervention
(Appendix L). A Wilcoxon Signed-Ranks Test indicated that the total depression attitude post
score was not statistically significant higher than the total pre-test scores z = -.846, p = .397. The
results indicate that there is no change in depression attitude after the intervention (Appendix M).
Discussion
The proponent conducted a quantitative descriptive research design, testing the implementation
of a depression care management program to identify the home health nurses’ depression
knowledge and attitude.
Limitations

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The major limitation of this study is the small sample size from a convenience sample on
a fairly homogenous population. Although multiple attempts and 2 intervention dates were
offered to recruit additional participants, scheduling was a challenge as the nursing staff works in
the community. This affects the findings’ generalizability and might have biased results.
Recommendation
To address the small sample size and to increase the retention of participants,
administrators of the home health agencies should incorporate the depression care management
in the new hire orientation program and to provide home health nurses’ incentives during the inservice training. In addition, further research studies should focus on measuring factors that
affect work preferences. The study can be also replicated to more than one home health agency.
Implication & Future research
Patient. The depression CAREPATH is a multi-disciplinary depression care
management approach, which complies with the Community Preventative Services Task Force
recommendation.
Provider. Utilizing an evidenced-based practice program in a home health setting
increases the competencies of nurses in making critical decision-making and coordination of
care.
System. For the administrative standpoint, the depression care management is a costeffective intervention, since there is no need to employ psychiatric specialized nurses, nor
increase the frequency of home health nurse visit. The additional cost is primarily in conducting
in-service training for home health nurses, office staff, intake coordinators, and RN case
manager. With the implementation of a DCM and its positive influence in quality patient
outcomes, utilizing the DCM might increase the home health agency’s total revenue with

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increase in referrals from psychiatric nurse practitioners, psychiatrist, and primary care
providers.
Sustainability. The DCM includes a start-up toolkit for home health agency and an elearning module.
Conclusions
The findings of this study show that home health nurses have minimal to moderate
knowledge of depression, and that the intervention increased their depression knowledge. With
this, the DCM can be utilized by other home health agencies, as it addressed the continuous need
to utilize evidenced-based practices in a home health setting and it can also serve as an initial
tool to address sustainability of change locally and nationally. Incorporating the depression care
management protocol on home health nurses’ visits can increase the detection of depression,
improve treatment and outcomes. Home health nurses can assess, evaluate, and monitor patient’s
overall well being, while collaborating to PCP for recommendation and treatment.

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Appendix A

Figure A1
EBSCOhost Database Screenshot

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Appendix B

Figure B1
Proquest Database Screenshot

Figure B2
PubMed Database Screenshot

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Appendix C

Figure C
Chronic Care Model

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Appendix D

Figure D
The Iowa Model