Depressive symptoms in medical patients are associated with increased healthcare utilization, including post-discharge readmissions at rates 73% higher than that of their non-depressed counterparts. In prior work, we showed that a ReEngineered Discharge (RED) that standardized discharge processes improved readmission rates in patients with depressive symptoms, but they remained significantly higher than those without depression. In this project we evaluate the impact of adding Collaborative Care for depression to RED in an attempt to lower readmission rates for those patients with depressive symptoms. Design: Two-arm Randomized Controlled Trial Hypotheses: The combination of Collaborative Care for depression and the RED program will (1) decrease 30 and 90 day readmission rates and (2) improve mental health related quality of life more than patients receiving RED alone. Population Studied: Patients admitted to a general medical service at an urban safety net hospital. The subjects studied represent low-income, ethnically diverse urban populations, who have all screened positive for depression. This study meets AHRQ guidelines for the inclusion of priority populations in research. The intervention is designed to be used while subjects are inpatient and then for 12 weeks post-discharge as an outpatient. Methods: After adapting and testing the intervention, 1052 patients over 18 years old, admitted to the general medical service of Boston Medical Center with at least a moderate level of depressive symptoms (Patient Health Questionnaire score e10) will be enrolled and randomized into one of 2 groups (1) 526 receiving our "Re-engineered Hospital Discharge" intervention, a set of 11 discrete, mutually reinforcing components provided by a care manager and re-enforced by a telephone call 2-4 days after discharge by a clinical pharmacist (RED), and (2) 526 receiving the RED plus 12 weeks of collaborative care for depression including a care manager to deliver via weekly telephone calls a set of interventions in conjunction with patients'primary care physician and personal preferences: depression self-management program, psychopharmacology, and referral to mental health professionals (RED-D). Outcome Measures: The primary patient centered outcomes are the 30 and 90 day subsequent hospital readmission. Secondary outcomes include (1) mental health status as measured by the SF-36 and (2) cost analysis. Expected Results: This project will provide valuable information about whether including collaborative care for depression in a standardized discharge process will improve readmission rates.

Public Health Relevance

Hospital readmission is now a major focus of national health care policy. One out of every 10 hospital stays included a diagnosis of mood disorders (over 3.3 million stays) and these patients are much more likely to be readmitted to the hospital. In an attempt to lower the rehospitalizaton rates of patients with depressive symptoms, this project will augment the ReEngineered Discharge (RED) -- an evidence-based process to prepare patients for discharge -- with a care treatment program for depression using a care manager in collaboration with primary care physicians to deliver self-management education, antidepressant medication and referral to mental health professionals.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Project (R01)
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Health Care Quality and Effectiveness Research (HQER)
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Mullican, Charlotte
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Boston Medical Center
United States
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