For older adults, social health often has a direct impact on mental health and well-being. Older adults today face a diversity of needs health care providers alone cannot address. Because many of these needs stem from complex social and structural challenges, recent national guidelines suggest that broader integration of health care with social care and community-based services may further strengthen care and enhance outcomes.
A movement toward community-based care models and social service partnerships may help bolster capacities to better serve our aging population. Archstone Foundation has been at the forefront of developing innovative solutions to meet these needs.
The Care Partners Project was initiated in 2014 by Archstone Foundation, University of Washington, and University of California, Davis to build on evidence-based collaborative care through primary care partnerships with community-based organizations (CBOs).
The enhanced collaborative care model aims to strengthen depression care for older adults by sharing depression care tasks and accountability across organizations that might already be serving many of the same patients. The project also extends outreach and services into the community setting, where older adults with depression may be more comfortable engaging in treatment. The multi-site project engaged two cohorts of clinic-CBO partnerships, located throughout California, between 2015-2021.
Bolstering Cross-Organizational Capacities
Interviews with service providers at Care Partners sites have revealed many benefits and challenges of partnering across sectors and organizations. Community-based organizations have made valuable contributions in serving older adults with depression, including:
- Bringing new services to supplement the collaborative care approach.
- Strengthening core aspects of collaborative care (e.g., measurement-based care; brief psychotherapy).
- Building trust and expanding reach within the community.
- Illuminating patients’ social contexts.
For example, several CBO partners involved in Care Partners offer home visits to patients, which have allowed care providers to see and understand patients within their social and home environments. In many cases, these visits have revealed critical risk factors for patients’ health and safety that would otherwise not have been identified within clinic walls. In this way, Care Partners has bolstered cross-organizational capacities to identify and mitigate social needs often thought to be outside the realm of clinical care.
A More Holistic Approach to Late-Life Depression Care
Our findings highlight the importance of addressing unmet social needs in community settings as part of a holistic approach to late-life depression care and, in many cases, as a condition of providing effective treatment. In our conversations with service providers from Care Partners sites, several challenges were discussed in providing depression care to older adults, including housing insecurities or quality issues, food and economic insecurities, lack of adequate or reliable transportation, social isolation, and family challenges.
Social needs were most often identified through home visits with patients, conducted by CBO care managers, or through conversations at program intake. Some program intake sites used the PRAPARE assessment tool, which is specifically designed for needs related to the social determinants of health — conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes.
Care Partners sites approached these challenges in various ways, with the CBOs often taking a lead role in mitigating non-medical needs. These approaches tended to fall within a broad theme of establishing connections: Service providers connected patients with resources, serving as advocates and helping them navigate healthcare and social service systems; they built relationships with patients, offering a human connection that was often lacking in older patients’ social lives; and they supported a sense of empowerment among patients, strengthening resiliency and connection to self among patients who providers suggested, in many cases, felt a lack of control over their lives.
Service providers from both clinics and community-based organizations shared success stories of patients who benefited from the partnered approach to depression care; however, the value of partnering across organizations and of addressing social needs in this context went beyond individual patient outcomes.
The engagement of a community-based organization in the depression care workflow enhanced the visibility of social needs for all members of the care team, allowing Care Partners sites to provide a more holistic approach to care. This approach moved beyond the walls of the clinic and gave attention to the implications of patients’ social worlds and home environments on their depression symptoms and their ability to engage in and benefit from depression treatment.
A Unique Learning Opportunity
Over the course of the project, several sites grew in recognition that clinically relevant symptoms of depression cannot be separated from the social worlds in which patients live, particularly among older adults who often have unique stressors such as mobility issues, medical complications, and relatedly, limited social support.
For many cases described by participants, circumstances of everyday life affected patients’ depression symptoms, their abilities to access treatment, and their responses to treatment. Community-engaged partnerships, coupled with greater attention to the roles of social needs and home environments, may improve reach and quality of care for older adults living with depression.
We have also learned important lessons about how primary care clinics and CBOs can most effectively develop and sustain partnerships to support holistic care.
Building on these insights, Archstone Foundation, along with University of Washington and University of California, Davis, is supporting a learning collaborative for clinic and community-based organization partners in California.
To learn more about this unique learning opportunity, please visit the Care Partners website and/or read our previous blog post about it. You can also register for the Request for Proposals (RFP) Q & A webinar being held on January 28, 2021 at 9 a.m. Pacific Time.
