Digital Repository Doctoral Projects Fall 2022 Lift Up, Reach Up: Promoting Depression Care of Older Adults in Assisted Living Angela Sue Bishop Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Bishop, A. S. (2022) Lift up, reach up: Promoting depression care of older adults in assisted living. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 1 ______________________________ ____________________________ Lift Up, Reach Up: Promoting Depression Care of Older Adults in Assisted Living by Angela Sue Bishop, DNP-FNP student, RN A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah 10/03/2022 12/16/2022 _ _ _ Student Name, Credentials (Electronic Signature) Date Diane Leggett-Fife, PhD, RN 12/16/2022 DNP Project Faculty (Electronic Signature) Date Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Note: The program director must submit this form and paper. LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 2 Table of Contents Abstract ........................................................................................................................................... 5 Lift Up, Reach Up: Promoting depression Care of Older Adults in Assisted Living ..................... 6 Background and Problem Statement ........................................................................................... 6 Diversity of Population and Project Site ..................................................................................... 7 Significance for Practice Relative to Role-Specific Leadership ................................................. 8 Literature Review and Framework ................................................................................................. 8 Search Methods ........................................................................................................................... 9 Depression in the Older Adult .................................................................................................... 9 Definition and Risk Factors .................................................................................................... 9 Consequences and Effects on Health .................................................................................... 10 Older Adults Residing in Assisted Living Facilities................................................................. 11 Prevalence and Risk Factors ................................................................................................. 12 Barriers to Treatment ............................................................................................................ 12 Depression Treatment Options ................................................................................................. 13 A Plan to Train ALF Staff to Provide Depression Care ....................................................... 14 Screening............................................................................................................................... 14 Education and Referral ......................................................................................................... 15 Behavioral Activation ........................................................................................................... 16 Framework ................................................................................................................................ 16 LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 3 Discussion ................................................................................................................................. 17 Implications for Practice ........................................................................................................... 18 Project Plan ................................................................................................................................... 18 Project Design ........................................................................................................................... 18 Gap Analysis of Project Site and Population ............................................................................ 19 Cost Analysis and Sustainability of Project .............................................................................. 20 Project Outcomes ...................................................................................................................... 20 Consent Procedures and Ethical Considerations....................................................................... 21 Instruments to Measure Intervention Effectiveness .................................................................. 22 Project Implementation ................................................................................................................. 22 Project Intervention ................................................................................................................... 23 Staff Education...................................................................................................................... 23 Resident Assessment ............................................................................................................. 25 Resident Education ............................................................................................................... 25 Process Improvement ............................................................................................................ 26 Project Timeline ........................................................................................................................ 26 Project Evaluation ......................................................................................................................... 27 Data Maintenance and Security ................................................................................................ 27 Data Collection and Analysis.................................................................................................... 27 Staff Data Analysis ............................................................................................................... 28 LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 4 Resident Data Analysis ......................................................................................................... 30 Findings..................................................................................................................................... 31 Strengths ............................................................................................................................... 34 Weaknesses ........................................................................................................................... 35 Discussion ..................................................................................................................................... 35 Translation of Evidence Into Practice ....................................................................................... 36 Implications for Practice and Future Scholarship ..................................................................... 37 Sustainability......................................................................................................................... 38 Dissemination ....................................................................................................................... 38 Conclusion ................................................................................................................................ 39 References ..................................................................................................................................... 40 Appendix A ................................................................................................................................... 47 Appendix B ................................................................................................................................... 48 Appendix C ................................................................................................................................... 52 Appendix D ................................................................................................................................... 53 Appendix E ................................................................................................................................... 54 Appendix F.................................................................................................................................... 55 LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 5 Abstract Depression is prevalent in older adults residing in assisted living facilities (ALF), and facility staff often lack the knowledge to identify and respond to depression symptoms. Also, older adults do not understand treatment options for depression. Purpose: The DNP project was designed to determine if ALF staff could be trained to deliver depression care to older adult residents, resulting in decreased depression symptoms. Methodology: The project provided web-based and in-person training on late-life depression to local ALF staff to improve daily supportive care, including a behavioral activation (BA) group class. Pre-and post-tests assessed staff learning and an exit survey determined the ongoing feasibility of the education. Residents received depression screening, referral services, and inclusion in the group BA class. Depression screening scores were used to determine the benefit of the intervention, and an exit survey assessed the usefulness of the intervention. Results: Data analysis showed a slight increase in staff understanding of depression symptoms in older adults. Depression screening results of the residents participating in the BA class indicated a decrease in depression symptoms. Exit surveys indicated that both groups found the intervention helpful and would continue using this new knowledge in their day-to-day activities. Implications for Practice: Older adults often prefer therapy to medication for depression. This project provides a way to incorporate evidence-based depression care into the daily care received by older adults most often affected by depression. In addition, this intervention could be adapted to community settings, such as senior centers, to provide another referral option for primary care providers caring for this population. Keywords: depression in the elderly, depression in assisted living, behavioral activation, depression screening, staff education LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 6 Lift Up, Reach Up: Promoting depression Care of Older Adults in Assisted Living In 2019, 18.4% of senior adults (age 65 or older) in the United States experienced depression symptoms of varying severity (Villarroel & Terlizzi, 2020). Older adults experiencing depression often have advanced signs of aging that impact their quality of life (Alexopoulos, 2019). Late-life depression can cause an increased risk of falls, disability, and suicide ideation (Sirey et al., 2013). Additionally, older adults with depression have poor adaptation to chronic illness and decreased treatment adherence, leading to poor medical outcomes and increased morbidity and mortality (Ciechanowski et al., 2004). Approximately one million older adults live in assisted living facilities (ALFs), where depression is often undiagnosed and not treated (Beuscher & Dietrich, 2016). Depression is one of assisted living facilities' top five chronic conditions (Allen, 2015). Although antidepressants are often used as the only treatment for depression, the addition of psychotherapy can decrease relapse and recurrence (Alexopoulos, 2019; Raue et al., 2017). For seniors with depression who reside in assisted living facilities, screening, education, referral, and supportive care for depression can be provided by trained facility staff (Cernin & Lichtenberg, 2009; Meeks et al., 2014). Therefore, the primary purpose of this project is to educate ALF staff to provide screening, education, referral, and treatment to older adult residents. Background and Problem Statement In Weber and Morgan counties, Nobu Iizuka, Director of Aging Services, expressed concern regarding depression in the elderly population in these two counties (personal communication, January 27, 2021). As part of the local mental health agency, the director suggested that the aging department could help address depression in this population. Creating a LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 7 program to help ALF staff address depression experienced by their residents will allow the department to address this gap in services for the elderly population. Currently, depression care for older adult ALF residents consists of treatment by their primary care provider and referral to a mental health therapist, if available. ALF staff are uniquely positioned to assist with depression screening and support due to their daily interaction with residents. Still, they do not have an organized method to incorporate depression care into resident services. Facility nurses complete resident assessments biannually, but the assessment does not include an evidence-based geriatric depression screening tool. The facility activities staff schedule daily activities for residents but do not have a curriculum available to teach residents about depression and methods to decrease its effects on their lives. Finally, little educational material is available that assists direct care staff with recognizing and supporting residents experiencing depression. Diversity of Population and Project Site Weber Human Services is a community organization that provides mental health services and various community aging services to Weber-Morgan health district residents. The agency has a unique combination of mental health providers and aging department case managers to address the incidence of depression faced by ALF residents in this community. Assisted living facilities provide comprehensive daily care to their residents, including personal care, medication management, activity scheduling, and access to a facility nurse for assessment and care coordination. Staff at the ALFs vary widely in age, race, and education level. The primary beneficiaries of the project will be the older adults residing in ALFs. These individuals are culturally diverse and have a wide range of physical abilities and medical LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 8 diagnoses. In addition, many individuals experience difficulty with transportation, have a limited income, and have varying levels of social support from family and friends. Significance for Practice Relative to Role-Specific Leadership The American Psychological Association (2019) clinical practice guideline recommends depression treatments consisting of individual or group psychotherapy with the addition of a selective serotonin reuptake inhibitor if cognitive impairment is not present. Although created for psychologists, medical providers can benefit from this guideline by understanding the role of psychotherapy in depression treatment, the importance of discussing this treatment option, and a referral to a mental health provider. In addition, medical providers include practitioners with a Doctor of Nursing Practice (DNP). These individuals have the training to work with interdisciplinary teams within the community to implement evidence-based practices to influence patient outcomes. Improving the availability of community programs to assist with depression care for older, homebound adults will benefit patients and primary care providers by offering more treatment options to this vulnerable population. Literature Review and Framework This literature review aims to identify evidence-based interventions that ALF staff can use to address depression in older residents. Themes discovered during the literature review indicate that: (a) Depression is prevalent and debilitating in older adults residing in ALFs (Beuscher & Dietrich, 2016; König et al., 2019); (b) psychotherapy is preferred by older adults and more effective than oral antidepressant medication alone (Alexopoulos, 2019; Raue et al., 2017); and (c) ALF staff can be trained to provide depression screening, referral, education, and support to residents (Cernin & Lichtenberg, 2009; Meeks et al., 2014; Reyes et al., 2019). LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 9 The framework used for this project is the Model for Evidence-Based Practice Change, which supports synthesizing evidence and implementing evidence-based change into current practice (Rosswurm & Larrabee, 1999). Search Methods Search terms used for this project include depression in the elderly, depression in assisted living, aging, psychotherapy, behavioral activation, depression risk factors for the elderly, depression screening, consequences of depression in the elderly, and evidence-based practice change models. Databases used were: Google Scholar, PubMed, EBSCO, CINAHL, Science Direct, OVID, and Wiley. Database search exclusion criteria included: journal articles over 20 years old; articles that included dementia or multiple serious mental illness diagnoses. Depression in the Older Adult By 2030, it is estimated that one-fifth of the population in the United States will be over the age of 65, with 26% of that age group belonging to a racial or ethnic minority (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011). Changes in lifestyle, social support networks, and physical health and function can occur as individuals age, which increases the risk of major depressive disorder (MDD) and persistent depressive disorder (PDD). It is estimated that between 10% and 20% of older adults have symptoms of depression (Raue et al., 2017; Snow & Abrams, 2016; Tsoi et al., 2017). Definition and Risk Factors The American Psychological Association (2019) defines MDD as a sad or depressed mood or a lack of pleasure or interest in usual activities for more than two weeks. A change in appetite, sleeping pattern, fatigue, feelings of guilt or worthlessness, inability to concentrate, and LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 10 thoughts of death or suicide are additional symptoms that diagnose MDD. Similarly, PDD, previously known as dysthymia, is defined by a depressed mood most of the time for two years. A change in sleeping patterns, changes in appetite, fatigue, poor self-esteem, concentration problems, and hopelessness are additional symptoms of PDD. Older adults have unique symptoms that complicate diagnosis and treatment. Balsamo et al. (2018) suggest that the cognitive issues and memory loss present in depression can be incorrectly diagnosed as dementia. Older adults often report more body-wide symptoms but fewer episodes of sadness. Anxiety often precedes depression and requires assessment and treatment to prevent inadequate response to depression interventions. Finally, older adults are less likely to discuss mood, loss of pleasure, feelings of worthlessness, and other symptoms of depression. Awareness of the risk factors unique to elderly individuals, such as social isolation and stressful life events, can help health care and community service providers identify individuals or populations at high risk for depression (Cole & Dendukuri, 2003; Richardson et al., 2012). For example, a systematic review and meta-analysis of 20 qualitative and quantitative studies involving 23,058 subjects found that disability, sleep disturbance, bereavement, female gender, and prior diagnosis of depression were significant risk factors for depression (Cole & Dendukuri, 2003). Consequences and Effects on Health Sirey et al. (2013) indicated that mental health disorders are the second most significant cause of disability worldwide. Among these disorders, depression causes the highest burden in disability-adjusted life years. Older adults with depression have poor adaptation to chronic LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 11 illness and decreased treatment adherence, leading to poor medical outcomes and increased morbidity and mortality (Alexopoulos, 2019; Ciechanowski et al., 2004; Sirey et al., 2013). Suicide rates are higher in older adults than in other age groups, with major depression being the most common risk factor (Raue et al., 2017). Medical comorbidities, functional decline, alcohol or other substance abuse, and stressful events also increase the risk of suicide. The combination of poor social support and depression is especially concerning, and individuals exhibiting these symptoms should be evaluated for suicidal ideation (SAMHSA, 2011). Older adults who experience depression use more medical and social services, increasing costs to the individual and the community (Snow & Abrams, 2016). A meta-analysis and systematic review of 48 articles, including 55,898 individuals, completed by König et al. (2019) revealed that elderly patients with depression had a 73% higher direct cost of care than those without depression. Individuals with depression experience indirect costs through early retirement, reduced household productivity, problems managing finances, and an increased need for informal caregiving by friends and family (Snow & Abrams, 2016). Older Adults Residing in Assisted Living Facilities Physical limitations, such as vision, hearing, communication, mobility, cognition, and self-care, affect an older adult's ability to self-manage activities of daily living (Centers for Disease Control [CDC], 2021). In 2019, the CDC reported that 21.9% of Americans over age 65 experience functional limitations in at least one area. Individuals with these who require long-term care needs that are not at the level of the skilled nursing care given in the nursing home often reside in an ALF (Plys, 2017). ALFs provide housing, meals, personal care, medication management, and recreational activities, emphasizing psychosocial care. While this care supports LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 12 the physical needs of the older adult, the relocation often affects emotional and social support and increases the risk of depression (Beuscher & Dietrich, 2016). Prevalence and Risk Factors Depression is more common in seniors in long-term care facilities, such as nursing homes and ALFs (Abrams et al., 2016). The prevalence of major depression in long-term care is estimated to be 6% to 24%. Furthermore, rates of significant depression symptoms are believed to be between 38% and 44%. Depression rates in the long-term setting are three to four times higher than that of older adults living in their homes (Davison et al., 2018). Older adults often have depression at admission to an ALF, and the symptoms persist after the transition (Davison et al., 2018). The risk factors for ALF residents are similar to those of community-dwelling older adults, such as functional decline, cognitive impairment, and multiple medical diagnoses. However, living in a long-term care setting, such as an ALF, significantly increases depression symptoms. Relocation to the ALF affects the social support of these residents, drastically affecting friendships and community ties (Beuscher & Dietrich, 2016). Also, many minority groups, such as Latinos, African Americans, and women, have a high poverty rate during old age and are at greater risk for depression (SAMHSA, 2011). Barriers to Treatment Casado et al. (2008) described patient, provider, and organization barriers to treating depression in older adults. Patient barriers include transportation difficulties, concerns regarding the stigma attached to mental health treatment, and a lack of knowledge about treatment efficacy. Inadequate knowledge about depression in older adults is also a barrier for providers, as is an overall shortage of providers capable of managing treatment. Cultural differences between LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 13 medical, mental health, and social services providers prevent the coordination of services at the organizational level. Even if affordable and accessible treatment is available, elderly adults may not utilize it due to unique barriers related to their functional or socioeconomic status or cultural beliefs. Many older adults prefer to use religious or spiritual beliefs for depression treatment, turning to religious leaders for support and care (Choi & Morrow-Howell, 2007). Some individuals avoid mental health treatment due to dissatisfaction with previous treatment or distrust of mental health providers or treatments (Choi et al., 2014). Elderly individuals coping with chronic medical conditions must manage many medical appointments and services and may lack the energy to participate in depression treatment (Unützer et al., 2002). Depression Treatment Options The American Psychological Association (2019) clinical practice guideline recommends depression treatments consisting of individual or group psychotherapy, a selective serotonin reuptake inhibitor, and shared decision-making with the patient when choosing treatment for depression. Older adults have shown a preference for psychotherapy for depression treatment, expressing concerns regarding the side effects of antidepressants (Choi & Morrow-Howell, 2007; Raue et al., 2017). Antidepressants are not as effective in older adults. Only one-third of older adults achieve depression remission with antidepressant use (Raue et al., 2017), possibly due to poor adherence, subtherapeutic dosing, and inadequate monitoring (Choi et al., 2014). There is also a small increased risk of gastrointestinal bleeding in individuals over 70 who take an SSRI and a nonsteroidal anti-inflammatory drug (Siu et al., 2016). However, antidepressants used with psychotherapy can decrease relapse and recurrence, although recurrence is still common in older adults (Alexopoulos, 2019; Choi & Morrow-Howell, 2007). LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 14 A Plan to Train ALF Staff to Provide Depression Care For seniors who reside in an ALF, screening and depression care can be initiated by facility staff (Cernin & Lichtenberg, 2009). A mixed-method study of the Depression Treatment in Assisted Living (DT-AL) model found it feasible to incorporate depression care into the assisted living setting (Smith & Haedtke, 2013). This model utilized a facility care manager trained to educate residents about depression and coordinate with offsite care providers. Staff members were trained to recognize and respond to resident reports of depression, and the facility nurse screened for depression and coordinated with staff and primary care. Residents and staff responded favorably to this approach, although staff reported a lack of time to provide consistent, supportive depression care to residents. Behavioral treatment to address depression was also utilized in a pilot study by Cernin and Lichtenberg (2009). Staff in the ALF were trained to deliver treatment by scheduling pleasant events, such as social or physical activities, with the residents for thirty minutes three times a week for three months. ALF residents participating in this intervention experienced decreased depression symptoms and increased mood. Screening Successful treatment of depression in elderly adults begins with utilizing screening tools designed for this age group by providers equipped to interpret the results and move forward with treatment and reassessment (Siu et al., 2016). The US Preventative Services Task Force (USPSTF) recommended the use of the Geriatric Depression Scale (GDS) for this population and concluded that there was enough evidence to show that screening and treatment of depression were effective in older adults (Siu et al., 2016). LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 15 Tsoi et al. (2017) completed a systematic review and meta-analysis of 132 studies with 46,506 participants over the age of 60 to compare the Two-Question Screen for depression with 15 other screening instruments. The Two-Question Screen was comparable with the other instruments, including the GDS, and is recommended as an accurate depression screening tool for that population. As suicide risk increases for older people experiencing depression, a screening tool for suicide risk should be included in the screening process if the older adult expresses suicidal ideation or a history of attempts (Dube et al., 2010). The P4 Screener was helpful in the care of patients with depression. This tool allows the clinician to discuss current thoughts and past self-harm attempts, including any specific plans made, timeframes considered, and what might prevent the patient from attempting self-harm. Education and Referral Education regarding depression and treatment methods are essential to help overcome personal and cultural stigma (Choi & Morrow-Howell, 2007; Choi et al., 2014). Ideas essential to relay to older adults include: a) depression is a medical condition not normal to aging and is not a sign of weakness b) depression has identifiable symptoms and risk factors c) depression is treatable through self-care, psychotherapy, and medication (National Institute of Mental Health [NIMH], n.d.). Older adults are willing to accept various treatment modalities but may need education regarding the effectiveness of psychotherapy treatment. While antidepressant medication is not always preferred, patients should be taught about concerns that are justified and those that are not (Choi & Morrow-Howell, 2007). An essential part of depression care includes referral to primary care, mental health care, and other social service agencies (Casado et al., 2008). Many older adults receive mental health LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 16 care only from a primary care provider, despite their preference for psychotherapy (Choi & Morrow-Howell, 2007). Racial and ethnic minorities utilize formal mental health providers infrequently, especially if they have more concerning problems such as finances. Trained ALF staff, such as the facility registered nurse (RN), can assist with overcoming these barriers to treatment and initiating referrals. Behavioral Activation Raue et al. (2017) found that problem-solving therapy (PST) and cognitive behavior therapy (CBT) has the most robust evidence of efficacy for treating depression in older adults. PST addresses deficits in older adults' problem-solving ability to prevent depression caused by poor coping in stressful situations, such as poverty or illness (Choi et al., 2014). PST addresses anhedonia and psychomotor slowing by utilizing behavioral activation (BA). BA is effective because it addresses the environmental changes that can lead to depression (Ouijano et al., 2007). Older adults participating in BA choose simple goals vital to them and are most likely to have a positive outcome. Framework This quality improvement project utilizes the Model for Evidence-Based Practice Change framework to implement depression care for older adults residing in ALFs. This first step of the model involves assessing the need for change by identifying a problem, involving stakeholders, and comparing internal data with external data (Melnyk & Fineout-Overholt, 2019). ALF staff do not currently use standardized depression screening tools or provide ongoing support for depression symptoms and treatment. The second step of this framework involved locating evidence-based interventions that staff could use in an ALF (Rosswurm & Larrabee, 1999). Critical analysis of the evidence is the LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 17 third step and involves synthesizing the information and assessing the feasibility of the improvement along with the risks and benefits of implementation. Designing the practice change is the fourth step of the model (Melnyk & Fineout-Overholt, 2019). During this step, screening and education tools were selected for ALF staff to identify depression experienced by residents correctly. An education module was created to teach ALF staff how to apply depression interventions. After a brief education module, the ALF nurse screened residents for depression and provided referrals to primary care and mental health services. The ALF activities staff initiated a BA class to educate those residents with depression about their symptoms and the benefits of increasing their activity level. Ongoing education with staff helped identify the strengths and weaknesses of the program. The program's effect on the depression symptom of residents was assessed. Integrating the new practice and incorporating it as a standard of care is the final step of this model (Melnyk & Fineout-Overholt, 2019). This step involved extending this care to all residents who reside in the ALF, with the possibility of offering this program to other facilities in Weber County. Discussion Evidence from this literature review shows that ALF staff can successfully provide depression care to older adult residents (Smith & Haedtke, 2013). Staff members have an ongoing relationship with the residents that allow them to address social issues related to depression and provide education and a referral to mental health providers in the community. However, staff members have many responsibilities, making it challenging to provide this care to all residents. Depression can also become a secondary concern when older adults have severe and complex medical needs or have numerous social service needs, such as income and LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 18 transportation issues (Morrow-Howell et al., 2008; Pepin et al., 2017). Despite these limitations, the treatment infrastructure is available, and ALF staff can receive education to better coordinate depression care for their clients (Beuscher & Dietrich, 2016; Smith & Haedtke, 2013). Implications for Practice Practice guidelines and research show that older adults prefer psychotherapy over oral medication for depression treatment and respond better to combining the two treatment forms (Alexopoulos, 2019; American Psychological Association [APA], 2019). Older adults residing in the ALF will benefit from depression care provided by staff that can augment or replace pharmacological treatments. Primary care providers will have a resource available to assist with their most vulnerable patients' mental health and social needs. Improved mental health can decrease somatic symptoms in older adults (Ciechanowski et al., 2004; Sirey et al., 2013) and reduce the utilization of medical services (König et al., 2019; Snow & Abrams, 2016). Project Plan This quality improvement project involves enhancing depression care for residents in an ALF in Weber County through improved depression screening, a focus on depression education for staff, and a BA class for facility residents who screen positive for depression. ALF staff will better understand depression symptoms and treatment for older adults and how they can create therapeutic relationships with the residents. The ALF residents will learn that depression can be treated and participate in a class to help them use increased activity to decrease depression. Project Design This project aimed to improve the microsystems within the ALF to assist each group with addressing depression care for the residents (Pandhi et al., 2018). Staff education occurred online and in-person during monthly staff training and included general information and job-specific LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 19 training. Certified nursing assistants (CNAs) became supportive staff who could recognize and support residents with depression. The facility RN screened for depression and initiated a referral. The recreation staff led the BA class with the residents. These microsystems working together were equipped to improve resident care. Staff outcomes were measured through pre- and post-test with an exit survey. The BA class was carefully scripted using the Ten Year Revision of the Brief Behavioral Activation Treatment for Depression: Revised Treatment Manual (Lejuez et al., 2011). The class was taught to small groups of residents who also became a microsystem as they received enhanced depression care and were taught to recognize and address depression symptoms as they occur. Resident outcomes were measured as aggregate data using the GDS-15 screening tool. Residents also participated in an exit survey to assess the project's effectiveness. Gap Analysis of Project Site and Population This quality improvement project will affect residents over age 60 in the ALF. In addition, the main participants are the ALF staff who interact with and care for these residents. Primary care and local mental health providers will participate through referrals made by the facility RN when a resident screens positive for depression symptoms during the annual or biannual assessment. Key stakeholders include the ALF administrator and owners, who will be better equipped to provide quality care to residents through improved staff training. In addition, the local aging department at Weber Human Services (WHS) works to improve the health and wellness of older adults in the community. WHS is a community stakeholder that supports this project to address the mental health needs of older adults in the community. LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 20 Depression is prevalent but challenging to treat in ALF residents due to mental health stigma, transportation difficulties, and provider shortages (Casado et al., 2008). However, the APA (2019) recommends psychotherapy with medication treatment as optimal depression care, and ALFs have the ability and staff to implement this type of care on a group level. Cost Analysis and Sustainability of Project The budget requirements for this project have been discussed with the ALF and are approved. The main costs include staff training, which is required monthly and included in the facility budget. The facility will also cover the minimal expenses of copying materials for the resident BA class. See Appendix A for details of the cost analysis. The sustainability plan will include adjusting the staff and resident education based on the exit surveys. After improvements have been made to the education modules, all the training information and handouts will be available to the facility online and in printed form for future training and to maintain program integrity. The project information will also be available to interested facilities through the Weber County Aging department. Project Outcomes The two goals of this project are to increase staff knowledge about depression in older adults, support residents who experience depression, and use a group BA class to decrease symptoms in residents experiencing depression. Outcomes will be measured in several ways. Staff knowledge will be measured using a pre-post-test format during the education modules. The staff will complete a pretest, view the materials in the module, and complete the post-test, with multiple chances to complete the post-test to receive 100%. At the end of the project implementation, the staff will have the chance to complete an exit survey to assess their ability to use the information during the project and in future care activities. LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 21 Residents will be screened for depression symptoms using the GDS-15 tool. The first screening will determine if they require education and referral, Residents who score five or higher will receive referrals if accepted and participate in the BA group class. The GDS-15 will be administered at the end of the class to determine if these activities have decreased depression symptoms. At three months post-intervention, residents will complete the GDS-15 a final time to assess the interventions' effect's persistence. Residents will also complete an exit survey to assess their understanding of depression and confidence in pursuing treatment if symptoms return. Consent Procedures and Ethical Considerations This project was submitted to the Institutional Review Board (IRB) at Weber State University and the Utah Department of Human Services. Formal IRB approval was not needed from Weber State as the project was confirmed to have a quality improvement focus rather than research. The Department of Human Services IRB found the project exempt from IRB review as it is an educational project providing known interventions for depression treatment of residents in ALFs. Implementing a new program with the elderly adult population will require extra safeguards due to the perceived vulnerability of the population (Shivayogi, 2013). Therefore, the safety of the residents and informed consent were carefully addressed in this project. Delivering services to an older person in the ALF may reveal evidence of elder abuse. Individuals may make statements that lead to the belief that they are being abused. Utah state law requires anyone who suspects abuse of a vulnerable adult to report it to Adult Protective Services (Utah Department of Human Services, n.d.). Signs of abuse and how to report them have been addressed in the staff education modules. LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 22 The informed consent document was carefully constructed for the residents to ensure understanding. The document's font, literacy level, and length were tailored to the resident's needs and literacy levels. Residents are free to withdraw from the project at any time. Each participant will have a number that will be used to identify the scores of the three GDS-15 screenings that the facility nurse will administer. Screening results will be de-identified for the researcher, and this data will be reported in aggregate. Instruments to Measure Intervention Effectiveness Instruments used to measure effectiveness included the pre-post tests for the staff to measure knowledge acquisition (see Appendix B) and the exit survey to measure the usefulness and feasibility of the project (see Appendix C). These tests were reviewed for validity by a master's degree educator. The information from these tests and surveys will guide changes in the education modules and the intervention process. For the residents, the GDS-15 measured depression symptoms (see Appendix D). This screening tool is in the public domain and is available in several languages at https://web.stanford.edu/~yesavage/GDS.html. This data was reported in aggregate and identified if the BA education decreased depression symptoms. Residents also completed an exit survey to assess their experience with BA and depression education on the individual level (see Appendix E). This information will help guide changes in the BA group class. Project Implementation Project implementation began with identifying local ALFs with adequate nursing, CNA, and activities staff to participate in the project. Understaffing, management changes, and overall fatigue of healthcare workers from COVID-19 were barriers for facilities to implement this project. Potential candidates included those with regular activities staffing and an RN in the LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 23 facility routinely. Also, facility administrators who recognized the change in residents' mood and activity levels over the past two years were more likely to review this program. Project Intervention This project was implemented in two stages: staff education and resident assessment and education at a local ALF. The facility has a main building licensed as a level two facility and several smaller buildings licensed as level one facilities. Residents in the level one buildings had some ADL needs but were more ambulatory and could leave the facility independently if an emergency occurred. Residents in the level two facility were adults requiring help with activities of daily living (ADL) care and who could not leave the facility independently in case of an emergency (Utah Department of Health [UDOH], 2017). The facility had a capacity of over 40 but less than 120 residents and serves low-to-high- income residents, including those on Medicaid waivers. Residents at the facility are over the age of 40 years and have varying care needs and health issues. The staff members are diverse individuals with varying educational backgrounds, ranging from 17 to 50 years old. Staff Education Staff education was conducted in a hybrid format, including in-person instruction during a monthly staff meeting, self-paced instruction available through an online Canvas course, and weekly posters placed in the medication room to help encourage the completion of the education modules. First, an introduction meeting with staff was conducted to introduce the project's goals and how to sign up for the Canvas course. The first module about depression in older adults was taught to nine staff members, and the pretest and post-tests were completed. Four weeks were given to complete the Canvas course, after which the resident screening was completed. At the end of four weeks, the staff had not completed any Canvas modules, and the focus was shifted to LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 24 the poster presentation with the pretest and post-test available through Google Forms. Staff members were given text reminders and instructions for completing classes. Canvas Course Modules. The online Canvas course modules were designed for general education about depression in older adults and supporting and caring for those experiencing this illness. Four modules were designed for all staff members: depression basics, how to support and encourage older adults experiencing depression, how to address challenging situations during resident care, and the basics of BA for addressing depression. A mental health self-care module was also included in the general course. Additional specialized modules included instructions for the facility nurse for screening and referral and how to lead the group BA class for the activities staff. All learning modules included activities to assess prior knowledge, provide evidence-based information to improve learning and skill acquisition, encourage discussion, and assess knowledge improvement. Each module contained a pretest that combined multiple-choice, short answers, and fill-in-the-blank questions. The modules' learning portions included PowerPoint presentations with audio and video components. The post-test was identical to the pretest to identify improvements in staff knowledge. In-Person Class. Teams work together over time to achieve an outcome (Pandhi et al., 2018). While making changes to patient care, it was essential to meet with staff members to improve the implementation process and review the evidence-based practice change. A meeting with staff members selected by the facility occurred to explain the project, improve participation by staff, and show support for their efforts in caring for older adults. This meeting was a chance for staff members to ask questions, learn about depression in older adults, and share their experiences LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 25 caring for residents. Subsequent in-person meetings occurred with a few staff members who expressed specific questions or concerns. Resident Assessment The facility nurse assessed the residents for depression during the staff education process, and the GDS-15 screening was given to seven residents chosen by the facility. A score greater than five on the GDS-15 prompted the nurse to give the resident an educational pamphlet on depression and notify the resident's primary care provider of the results. The resident was offered a referral to a mental health provider, and services were arranged if requested. In addition, information about the BA group was given to the resident, who was invited to participate. Further assessments were available for cognitive testing and evaluating suicidality, if necessary. Residents who had a diagnosis of dementia could complete the Standardized Mini-Cog to ensure that they could participate in the BA group. For this project, a score of less than four on the mini-cog indicates some cognitive impairment and would exclude the resident and prompt a referral to primary care. In addition, residents who expressed thoughts of self-harm during the assessment could be screened with the P4 Suicidality screening tool, and proper referrals could be made to emergency services or primary care. These assessments were not needed during this implementation. Resident Education The group BA class was offered to three of the seven residents who were initially screened. One resident moved to another facility, and two residents passed away before the class began. The fourth resident was younger than the study parameters and was allowed to participate but not included in the study evaluation. The remaining three residents were invited to participate LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 26 in the BA group class scheduled to meet weekly for eight weeks. The class was to be led by the facility activities director. During implementation, the first three classes were taught over five weeks. The activities director reported difficulty coordinating a group class as the three residents had many reasons for not meeting. Poor group attendance required the instructor to meet with residents one-on-one to complete the classes. At the end of the third class, the activities director left the facility for a new job. A replacement instructor was not available at the facility to continue the class. Discussions with the facility administrator led to training a community volunteer to complete the remaining classes. Process Improvement Exit surveys were administered after the resident education class to improve staff and residents' experience. These anonymous surveys were created to assess the usefulness of the education for both residents and staff. Information was also gathered about the increased workload for facility staff and what changes they would make to improve workflow to continue to provide depression support to residents. The survey was administered to the staff anonymously online and the residents by the activities staff. Project Timeline The project timeline proceeded from the initial gap analysis and literature review to the development of the staff and resident education modules. IRB approval preceded the implementation phase. During the implementation phase, the timeline served as a tool for the ALF administrator and staff to move the interventions forward and prevent stagnation (see Appendix F). LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 27 Project Evaluation A two-part depression education program was offered at a local assisted living program to staff and residents. Nine staff members participated in an in-person education session followed by a web-based course utilizing a pre-and post-test format. The depression education program taught staff members about the symptoms of depression in older adults and how to provide supportive care to these residents. A 5-point Likert scale was used to evaluate the effectiveness and feasibility of the program for staff members. Residents were screened for depression and invited to participate in a group BA class. Participating residents learned to identify personal values, choose an activity that met their values, and identify an individual that could help them meet their goals. At the end of the class sessions, a 5-point Likert scale was used to evaluate the effectiveness of the BA class for residents, and a second depression screening was used to assess the intervention's effectiveness. Data Maintenance and Security Staff members could choose a unique username for their Canvas account and Google Forms submission if they did not want to use their legal name. Project data was stored on the password-protected website, while resident data was stored by the facility in the resident's physical chart. The facility kept the charts in a locked room and a locked cabinet. The information shared with the researcher was de-identified. Data Collection and Analysis Data for staff members was collected through various methods. Pre-and post-tests were collected at the in-person training, and the facility collected demographics. The exit survey was completed anonymously online through a Google Form. Resident data was collected by the facility RN, resident care coordinator, and activities director using a paper-based format. LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 28 Resident data included GDS-15 scores and the exit survey. Tests and survey results were inputted for analysis into Excel by the DNP student. Staff Data Analysis The sociodemographic characteristics of staff participants were obtained from the staff survey (see Table 1). Table 1 Sociodemographic Characteristics of Staff Participants Characteristic Facility Staff n % Gender Female 8 88.9% Male 1 11.1% Age 16-22 3 33.3% 23-29 5 55.6% 30-36 0 0 37 or older 1 11.1% Ethnicity White 8 88.9% Black 0 0 Hispanic/Latino 1 11.1% Native American 0 0 Asian 0 0 Note. N = 9 The pre-and post-test questions for staff members were identical (see Appendix B). The tests used multiple-choice, short-answer, and fill-in-the-blank questions to assess the participants learning after participating in the online modules. The tests for Module #1 were completed during the in-person class. Three employees left the facility during the education modules and did not complete the training. Subsequent modules were only completed by two of the remaining six staff members. However, only the post-test data was available as the pretests were not completed. Nevertheless, the pretest and post-test results for module one (see Table 2) indicate LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 29 that the education module resulted in a minor increase in staff understanding of depression in older adults. Table 2 Means and Standard Deviations of Staff Pretest and Posttest Scores Module Pretest Posttest M SD M SD Module #1 24.375 4.241 25.625 3.249 Note. Module #1 was taken by CNAs (N=8). The survey questions sought to determine the staff members perceived effectiveness of this intervention, how it affected their workload, and if they will continue to use this knowledge in the future (see Table 3). Two staff members completed the survey and found the education useful and the learning format easy to use. One respondent indicated that the process created a noticeable work burden, but both indicated they would incorporate this learning into daily care. Table 3 Results of Staff Survey Questions Regarding Depression Education Module Question Staff Responses Not at all Slightly Moderately Very Extremely 1. Previous knowledge of depression 0% 0% 0% 50% 50% 2. Education was important to reduce resident depression 0% 0% 0% 0% 100% 3. Depression training was adequate 0% 0% 50% 0% 50% 4. Confidence in new knowledge 0% 0% 0% 0% 100% 5. Ease of use of training modules 0% 0% 0% 50% 50% 6. New process created a work burden 50% 0% 0% 50% 0% LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 30 7. Incorporate learning into routine care 0% 0% 0% 0% 100% Note. N= 2 Resident Data Analysis The general resident sociodemographic data was limited to age and cognitive ability, with all participants aged 60 or over with no dementia diagnosis or thoughts of self-harm. Therefore, the RN did not need to administer the Standardized Mini-Cog or P4 Suicidality screener to any participant. Each participant exhibited a decrease in depression symptoms during the BA class. The mean GDS-15 score decreased from eleven to nine (see Table 4). Table 4 Means and Standard Deviations of Scores for GDS-15 Assessment GDS-15 scores M SD Before behavioral activation 11 2.646 At behavioral activation end 9 1.732 Note. GDS-15 was administered before the BA group class and after class completion. N=3 The resident survey questions sought to determine the residents' perceived effectiveness of the BA class, the support provided by facility staff, and their willingness to continue to use BA in the future (see Table 5). The three participating residents completed the survey and indicated a varied understanding of how to access depression treatment and the perception of support received from facility CNAs. In addition, the residents found the process of behavioral activation and the worksheets moderately to extremely useful and indicated they were very likely to continue using behavioral activation in the future. Table 5 LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 31 Results of Resident Survey Questions Regarding Behavioral Activation Intervention Question Resident Responses Not at all Slightly Moderately Very Extremely 1. Familiar with causes and effects of depression 0% 0% 33.3% 33.3% 33.3% 2. Understand how to access treatment 0% 33.3% 0% 33.3% 33.3% 3. Behavioral activation is useful 0% 0% 33.3% 33.3% 33.3% 4. Worksheets were easy to use 0% 0% 33.3% 0% 66.6% 5. Will continue to use behavioral activation 0% 0% 0% 33.3% 66.6% 6. Activity director was supportive 0% 0% 0% 66.6% 33.3% 7. Facility CNAs were supportive 0% 33.3% 0% 66.6% 0% Note. N=3 Findings The dual nature of this project resulted in numerous findings beyond the data obtained from surveys and screening tools. The process was evaluated during implementation by utilizing the Model for Evidence-Based Practice change, and some procedures were adapted to meet the needs of the facility and the residents (Rosswurm & Larrabee, 1999). Staff at the facility were not familiar with evidence-based practice or implementing a process improvement but were willing to attempt adapting their care routines to benefit the residents. Staff Education Results LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 32 Facility staff education was to be completed through an online, self-study format with nine facility staff members. However, this format was not well-received, and only two participants signed up for the course, with no one completing any modules. An attempt was made to educate through poster boards showing printed course material with the pre and post-tests available through Google Forms. This format also had little success as only two staff members participated and only completed post-tests. The limited number of staff participants made it impossible to collect further data about the effectiveness of staff education. In-person staff education was the most successful format for this particular facility. Staff attrition and facility requirements greatly impacted the education process. During the two-month education process, three participating CNAs left the facility for other employment. New employees were not invited to complete the depression education as part of their training. The training modules were voluntary for participating staff, and the facility did not elect to track staff participation beyond the first in-person class. The staff survey was administered anonymously through a Google Form, completed by two staff members (see table 3). While most responses were favorable regarding the education modules, one participant was neutral regarding the completeness of the depression education. Most significantly, one staff member felt that the new care process created a burden in routine care. Resident Education Results Resident depression screening was easily incorporated into routine care. The facility RN managed the process with assistance from trained facility staff. None of the residents screened elected to accept a referral to a mental health therapist, so it is unknown how well that process would work. All residents who were screened agreed to participate in the group BA class, and all LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 33 three individuals completed the class, including the exit survey and final GDS-15 screening. All participants had an overall decrease in depression symptoms during this intervention. One immediate finding was difficulty running the BA class as a group class. The facility activities director and, later, the community volunteer stated that although there were only three individuals, there was only one class when two participants were present. The rest of the classes were taught one-on-one. Reasons that residents did not attend a group class include illness, visits by home health providers during group class time, and anxiety about being in a group. During the BA class, both instructors expressed concerns with the worksheets. They observed that some residents had difficulty with vision and fine motor skills needed for writing. One resident also exhibited reading difficulties, requiring extra assistance from the instructor. Although the survey indicated that the residents thought the worksheets were easy to use, it would be beneficial to simplify the worksheets to accommodate the various needs of participants. The BA class required participants to choose an activity to complete, and it was anticipated that participants might choose an activity that required supplies. For example, one resident chose to have her nails done, which was completed by a friend. Another resident chose to practice Christmas songs, which did not require supplies as the facility had a piano. However, another resident wanted to make dominos, which created difficulty as staff members did not know how to teach this skill or obtain specialized supplies. While residents with adequate income or resources could be expected to provide their supplies, those with limited income must be guided to affordable activities. Alternatively, the facility could seek community donations to provide more opportunities to residents with limited incomes. The most crucial finding for resident education was the role of the activity director. During this process, the facility had two activity directors leave for other jobs. This lack of LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 34 continuity made it difficult for residents to maintain progression throughout the BA class. Utilizing a community volunteer to complete the class benefited residents since the individual was focused on the class and not distracted by other work duties. However, communication between the volunteer and the facility staff was complicated and required extra effort. Also, the volunteer did not know the residents, the facility policies and procedures, or a staff member. Nevertheless, community volunteers could be successfully used to fill gaps in facility staffing and improve depression care for residents. The resident survey was administered in a paper-based format at the end of the last class. Of particular interest is that one resident indicated they do not understand how to access treatment for depression. Also, one resident felt that facility CNAs were not particularly supportive during this process. Strengths The strength of this project was the dual education of participating residents and staff. A culture of teamwork was created for a short time by educating staff and residents about symptoms of depression in older adults. During one follow-up meeting with staff members, a CNA commented that she was surprised that one resident she spoke to expressed a strong feeling of depression and became tearful. When they discussed the BA class to help that feeling, the resident appreciated that assistance would be available to address these symptoms. Although it was found during the process that the group format for the BA class was challenging to manage, there were apparent benefits when residents met together. The community volunteer discussed the strengths of a group class. She observed one resident discussing a goal to play Christmas songs at a party for residents and families. She invited the other resident to participate in planning this activity, and the second resident readily agreed and LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 35 took part in the planning. Knowing that isolation is one of the symptoms of depression (Cole & Dendukuri, 2003; Richardson et al., 2012), a group BA class can be an essential part of breaking the depression cycle. Weaknesses The main weakness of this project is the small number of residents participating in the BA class. A larger number of participants would provide more data to evaluate the intervention's effectiveness better. Also, time constraints prevented the completion of the final GDS-15 screening scheduled for three months after completing the BA class. Therefore, it is unknown if the effect of BA on depression symptoms will persist past the end of the class. A similar weakness was found in staff education due to the small sample size, staff attrition, and the voluntary nature of the education. Staff could participate if they chose, but the facility did not require it beyond the first in-person class. Again, this could have impacted participation. Finally, staff attrition greatly impacted the ability to maintain the resident's group BA class. The loss of two activity directors during this process delayed the class's completion and disrupted the class's flow. Through the use of a community volunteer, the class was completed. However, the project was only completed with the flexibility to use a volunteer and quick access to a willing and teachable individual. Discussion Late-life depression can cause an increased risk of falls, disability, and suicide ideation (Sirey et al., 2013) and lead to poor adaptation to chronic illness with increased morbidity and mortality (Ciechanowski et al., 2004). ). For seniors with depression who reside in ALFs, screening, education, referral, and supportive care for depression can be provided by trained LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 36 facility staff (Cernin & Lichtenberg, 2009; Meeks et al., 2014). The primary purpose of this project was to provide supportive care to older adults in ALF experiencing depression by educating ALF staff to provide screening, education, referral, and treatment to these residents. Translation of Evidence Into Practice A review of the literature established that between 10% and 20% of older adults have symptoms of depression (Raue et al., 2017; Snow & Abrams, 2016; Tsoi et al., 2017). In long-term settings, such as ALFs, these rates are three to four times higher (Davison et al., 2018). The APA recommends antidepressants used with psychotherapy, which decreases relapse and recurrence (Alexopoulos, 2019; Choi & Morrow-Howell, 2007). This project utilized an element of psychotherapy called BA in a group format taught by trained assisted living staff to reduce depression symptoms in older adults. Staff members were also trained to identify residents experiencing depression and provide ongoing depression education and support to these residents. Previous studies found that staff can be trained to identify depression in older adult residents and coordinate care, although finding time to provide support was a significant barrier (Smith & Haedtke, 2013). However, the method of staff education was not explicitly discussed. Therefore, this project sought to utilize online staff education to improve depression care. In the end, three modes of education were attempted, including online self-study, in-person learning, and passive self-study in the form of biweekly poster presentations. In this staff population, in-person training exhibited the best results. The residents who were approached to participate in depression screening and education were willing and able to complete the process. Some adjustments can be made to worksheets to help older adults utilize them more effectively and independently. However, the most unexpected LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 37 part of the process was using a community volunteer to complete the classes. Many ALFs experience staff attrition and low staff-to-resident ratios that may make this depression care process challenging to implement. Utilizing volunteer organizations to find individuals who can be trained to lead BA group classes increases the opportunity to provide this service to older adults. It also increases overall education in the community about mental health issues, which can help increase awareness and reduce stigma. Implications for Practice and Future Scholarship Depression is a common condition treated in primary care practice. For patients with depression and anxiety, two-thirds of those diagnosed have their condition treated in a primary care clinic (American Academy of Family Physicians [AAFP], 2020). Furthermore, practice guidelines and research show that older adults prefer psychotherapy over oral medication for depression treatment and respond better to combining the two treatment forms (Alexopoulos, 2019; American Psychological Association [APA], 2019). Primary care providers working with older adults can collaborate with community partners to encourage comprehensive, evidence-based mental health care through staff and patient education. Future studies could focus on delivery methods for ALF staff members and older adults. Improvements could be made to staff education to encourage participation and streamline the education process. Also, one staff member reported an increased workload related to the intervention, making it essential to examine the feasibility of this intervention for staff members in ALFs. Resident participation was planned as a group class but evolved into one-on-one instruction. Future research could compare these two methods and explore why residents might be reluctant to participate in a group class. Furthermore, resident participation could be extended LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 38 to different age groups rather than only those aged 60 and over. Finally, the group class format could be extended to other older adult group settings, such as senior citizen centers. Sustainability The entire project will be housed with the Aging department at Weber Human Services and available to any interested facilities. Staff education remains available through the online platform Canvas Free-for-Teachers (https://www.instructure.com/canvas/try-canvas). In addition, interested facilities can identify an implementation champion who can access the course as a teacher, allowing them to make groups and monitor the progress of the staff members in their facility. The course is also available through email if facilities wish to use PowerPoint presentations to teach the classes in person. Dissemination Dissemination is an essential aspect of the project due to the lack of information available regarding staff development and ALF resident treatment for depression in older adults. The project is available online through the Weber State University Doctor of Nursing Practice Project repository (https://weber.edu/Nursing/GradProjects.html). A poster presentation was also given to DNP students and faculty at Weber State University. Finally, a report of the project results was given to staff and administration at the participating ALF, including ways to continue this intervention for more residents. Community stakeholders will also receive the results of this project. As the county agency tasked with addressing the needs of older adults, the Aging Services at WHS will receive the project to share with facilities in the area. In addition, information regarding the project will be incorporated into the WHS Aging website with information on how to receive the information to pursue staff education and the resident BA class. Finally, a synopsis of the project and results LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 39 will be submitted to the Utah Assisted Living Association with the option for an in-person presentation of the project for association members wishing to incorporate the interventions in their facilities. Conclusion Depression in older adults residing in assisted living is prevalent and debilitating. Still, it can be addressed through holistic care provided by mental health and primary care clinicians and staff at assisted living facilities. Through staff education regarding signs of depression in older adults, the residents can enjoy more personalized support and individualized mental health care. Access to mental health services can be difficult due to stigma, cost, transportation, and knowledge of efficacy. Bringing basic mental health care to the residents can increase acceptance and completion of elements of psychotherapy. Health professionals working with older adults in ALFs should recognize that medication is not the only treatment for depression. There are elements of psychotherapy that can be incorporated into care provided by facilities if staff and providers look for ways to identify and support these individuals where they live to improve their quality of life. LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 40 References Abrams, R. C., Nathanson, M., Silver, S., Ramirez, M., Toner, J. A., & Teresi, J. A. (2016). A training program to enhance recognition of depression in nursing homes, assisted living, and other long-term care settings: Description and evaluation. Gerontology & Geriatrics Education, 38(3), 325–345. https://doi.org/10.1080/02701960.2015.1115980 Alexopoulos, G. S. (2019). Mechanisms and treatment of late-life depression. Translational Psychiatry, 9(1), Article 188. https://doi.org/10.1038/s41398-019-0514-6 Allen, J. (2015). Depression in assisted living. Geriatric Nursing, 36(1), 78–80. https://doi.org/10.1016/j.gerinurse.2014.12.005 American Academy of Family Physicians. (2020). Mental health care services by family physicians (Position paper). www.aafp.org. Retrieved September 7, 2022, from https://www.aafp.org/about/policies/all/mental-health-services.html#Mental%20Health%20Care%20Services%20by%20Family%20Physicians%20(Position%20Paper) American Psychological Association (APA). (2019, February 16). Clinical practice guideline for the treatment of depression across three age cohorts. Retrieved March 15, 2021, from https://www.apa.org/depression-guideline/guideline.pdf Balsamo, M., Cataldi, F., Carlucci, L., Padulo, C., & Fairfield, B. (2018). Assessment of late-life depression via self-report measures: A review. Clinical Interventions in Aging, 13, 2021–2044. https://doi.org/10.2147/cia.s178943 Beuscher, L., & Dietrich, M. (2016). Depression training in an assisted living facility: A pilot study. Journal of Psychosocial Nursing and Mental Health Services, 54(5), 25–31. https://doi.org/10.3928/02793695-20160201-01 LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 41 Casado, B. L., Quijano, L. M., Stanley, M. A., Cully, J. A., Steinberg, E. H., & Wilson, N. L. (2008). Healthy ideas: Implementation of a depression program through community-based case management. The Gerontologist, 48(6), 828–838. https://doi.org/10.1093/geront/48.6.828 Centers for Disease Control. (2021, March 1). Disability and functioning. www.cdc.gov. Retrieved April 3, 2021, from https://www.cdc.gov/nchs/fastats/disability.htm Cernin, P. A., & Lichtenberg, P. A. (2009). Behavioral treatment for depressed mood: A pleasant events intervention for seniors residing in assisted living. Clinical Gerontologist, 32(3), 324–331. https://doi.org/10.1080/07317110902896547 Choi, N. G., & Kimbell, K. (2008). Depression care needs among low-income older adults: Views from aging service providers and family caregivers. Clinical Gerontologist, 32(1), 60–76. https://doi.org/10.1080/07317110802474742 Choi, N. G., & Morrow-Howell, N. (2007). Low-income older adults' acceptance of depression treatments: Examination of within-group differences. Aging & Mental Health, 11(4), 423–433. https://doi.org/10.1080/13607860600963802 Choi, N. G., Wilson, N. L., Sirrianni, L., Marinucci, M. L., & Hegel, M. T. (2014). Acceptance of home-based telehealth problem-solving therapy for depressed, low-income homebound older adults: Qualitative interviews with the participants and aging-service case managers (K. Van Haitsma, Ed.). The Gerontologist, 54(4), 704–713. https://doi.org/10.1093/geront/gnt083 Ciechanowski, P., Wagner, E., Schmaling, K., Schwartz, S., Williams, B., Diehr, P., Kulzer, J., Gray, S., Collier, C., & LoGerfo, J. (2004). Community-integrated home-based LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 42 depression treatment in older adults. Journal of the American Medical Association, 291(13), 1569–1577. https://doi.org/10.1001/jama.291.13.1569 Cole, M. G., & Dendukuri, N. (2003). Risk factors for depression among elderly community subjects: A systematic review and meta-analysis. American Journal of Psychiatry, 160(6), 1147–1156. https://doi.org/10.1176/appi.ajp.160.6.1147 Davison, T. E., You, E., Doyle, C., Bhar, S., Wells, Y., & Flicker, L. (2018). Psychological therapies for depression in older adults residing in long-term care settings. Cochrane Database of Systematic Reviews, (6), Article: CD013059. https://doi.org/10.1002/14651858.cd013059 Dube, P., Kroenke, K., Bair, M. J., Theobald, D., & Williams, L. S. (2010). The p4 screener. The Primary Care Companion to The Journal of Clinical Psychiatry, 12(6), e1–e8. https://doi.org/10.4088/pcc.10m00978blu König, H., König, H., & Konnopka, A. (2019). The excess costs of depression: A systematic review and meta-analysis. Epidemiology and Psychiatric Sciences, 29, e30. https://doi.org/10.1017/s2045796019000180 Lejuez, C., Hopko, D. R., Acierno, R., Daughters, S. B., & Pagoto, S. L. (2011). Ten year revision of the brief behavioral activation treatment for depression: Revised treatment manual. Behavior Modification, 35(2), 111–161. https://doi.org/10.1177/0145445510390929 Meeks, S., Van Haitsma, K., Schoenbachler, B., & Looney, S. W. (2014). Be-activ for depression in nursing homes: Primary outcomes of a randomized clinical trial. The Journals of Gerontology: Series B, 70(1), 13–23. https://doi.org/10.1093/geronb/gbu026 LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 43 Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare (4th ed.). Wolters Kluwer Health. Morrow-Howell, N., Proctor, E., Choi, S., Lawrence, L., Brooks, A., Hasche, L., Dore, P., & Blinne, W. (2008). Depression in public community long-term care: Implications for intervention development. The Journal of Behavioral Health Services & Research, 35(1), 37–51. https://doi.org/10.1007/s11414-007-9098-7 National Institute of Mental Health. (n.d.). Older adults and depression: Learn the signs and find the treatment. https://www.nimh.nih.gov/. Retrieved July 10, 2021, from https://www.nimh.nih.gov/health/publications/older-adults-and-depression/ Ouijano, L. M., Stanley, M. A., Petersen, N. J., Casado, B. L., Steinberg, E. H., Cully, J. A., & Wilson, N. L. (2007). Healthy IDEAS: A depression intervention delivered by community-based case managers serving older adults. Journal of Applied Gerontology, 26(2), 139–156. https://doi.org/10.1177/0733464807299354 Pandhi, N., Kraft, S., Berkson, S., Davis, S., Kamnetz, S., Koslov, S., Trowbridge, E., & Caplan, W. (2018). Developing primary care teams prepared to improve quality: A mixed-methods evaluation and lessons learned from implementing a microsystems approach. BMC Health Services Research, 18(1), 847. https://doi.org/10.1186/s12913-018-3650-4 Pepin, R., Leggett, A., Sonnega, A., & Assari, S. (2017). Depressive symptoms in recipients of home- and community-based services in the United States: Are older adults receiving the care they need? The American Journal of Geriatric Psychiatry, 25(12), 1351–1360. https://doi.org/10.1016/j.jagp.2017.05.021 LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 44 Plys, E. (2017). Recreational activity in assisted living communities: A critical review and theoretical model. The Gerontologist, 59(3), e207–e222. https://doi.org/10.1093/geront/gnx138 Raue, P. J., McGovern, A. R., Kiosses, D. N., & Sirey, J. (2017). Advances in psychotherapy for depressed older adults. Current Psychiatry Reports, 19(9), 57. https://doi.org/10.1007/s11920-017-0812-8 Reyes, D. V., Patel, H., Lautenschlager, N., Ford, A. H., Curran, E., Kelly, R., Lai, R., Chong, T., Flicker, L., Ekers, D., Gilbody, S., Etherton-Beer, C., Giudice, D. L., Ellis, K. A., Martini, A., & Almeida, O. P. (2019). Behavioural activation in nursing homes to treat depression (ban-dep): Study protocol for a pragmatic randomised controlled trial. BMJ Open, 9(10), e032421. https://doi.org/10.1136/bmjopen-2019-032421 Richardson, T. M., Friedman, B., Podgorski, C., Knox, K., Fisher, S., He, H., & Conwell, Y. (2012). Depression and its correlates among older adults accessing aging services. The American Journal of Geriatric Psychiatry, 20(4), 346–354. https://doi.org/10.1097/jgp.0b013e3182107e50 Rosswurm, M., & Larrabee, J. H. (1999). A model for change to evidence-based practice. Image: The Journal of Nursing Scholarship, 31(4), 317–322. https://doi.org/10.1111/j.1547-5069.1999.tb00510.x Shivayogi, P. (2013). Vulnerable population and methods for their safeguard. Perspectives in Clinical Research, 4(1), 53. https://doi.org/10.4103/2229-3485.106389 Sirey, J., Greenfield, A., DePasquale, A., Weiss, N., Marino, P., Alexopoulos, G. S., & Bruce, M. L. (2013). Improving engagement in mental health treatment for home meal recipients LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 45 with depression. Clinical Interventions in Aging, 8, 1305–1312. https://doi.org/10.2147/cia.s49154 Siu, A. L., Bibbins-Domingo, K., Grossman, D. C., Baumann, L., Davidson, K. W., Ebell, M., García, F. R., Gillman, M., Herzstein, J., Kemper, A. R., Krist, A. H., Kurth, A. E., Owens, D. K., Phillips, W. R., Phipps, M. G., & Pignone, M. P. (2016). Screening for depression in adults: US Preventative Task Force recommendation statement. Journal of the American Medical Association, 315(4), 380–387. https://doi.org/10.1001/jama.2015.18392 Smith, M., & Haedtke, C. (2013). Depression treatment in assisted living settings: Is an innovative approach feasible? Research in Gerontological Nursing, 6(2), 98–106. https://doi.org/10.3928/19404921-20130114-01 Snow, C., & Abrams, R. (2016). The indirect costs of late-life depression in the United States: A literature review and perspective. Geriatrics, 1(4). https://doi.org/10.3390/geriatrics1040030 Substance Abuse and Mental Health Services Administration (SAMHSA). (2011). The treatment of depression in older adults: Depression and older adults: Key issues (HHS Pug. No. SMA-11-4631). US Department of Health and Human Services. https://store.samhsa.gov/sites/default/files/d7/priv/sma11-4631-keyissues.pdf Tsoi, K. F., Chan, J. C., Hirai, H. W., & Wong, S. S. (2017). Comparison of diagnostic performance of two-question screen and 15 depression screening instruments for older adults: Systematic review and meta-analysis. British Journal of Psychiatry, 210(4), 255–260. https://doi.org/10.1192/bjp.bp.116.186932 LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 46 Unützer, J., Keaton, W., Callahan, C. M., Williams, J. W., Jr, Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Hitchcock Noel, P., Lin, E. H., Arean, P. A., Hegel, M. T., Tang, L., Belin, T. R., Oishi, S., & Langston, C. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. Journal of the American Medical Association, 288(22), 2836–2845. https://doi.org/10.1001/jama.288.22.2836 Utah Department of Health (UDOH). (2017, March 1). Assisted living interpretive guidelines. https://health.utah.gov/hflcra/facinfo/ALINTERPRETIVEGUIDELINESFEB17.pdf. Retrieved April 2, 2022, from https://health.utah.gov/hflcra/facinfo/ALINTERPRETIVEGUIDELINESFEB17.pdf Utah Department of Human Services. (n.d.). Adult protective services: Reporting abuse. https://www.daas.utah.gov. Retrieved May 29, 2021, from https://daas.utah.gov/adult-protective-services/ Villarroel, M. A., & Terlizzi, E. P. (2020). Symptoms of depression among adults: United States, 2019 (NCHS Data Brief No. 379). National Center for Health Statistics. https://www.cdc.gov/nchs/data/databriefs/db379-H.pdfLIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 47 Appendix A Budget Item Budget Notes One-Time Training Expenses Staff training: 2 hour 1-hour independent study and 1-hour in-person training absorbed by the facility as part of required training hours Resident Care Coordinator ($15/hr) $30.00 Activities staff (1 @ $11/hr) $22.00 Registered Nurse ($25/hr) $50.00 CNAs (10 @ $12/hr) $240.00 Total $342.00 Capital Costs Training room use $0 Absorbed by facility Computers for training $0 Absorbed by facility Total $0 Ongoing Costs Software $0 Public domain, no cost Copier fees $0 Absorbed by facility Ongoing training and new-hire training $377.00 Absorbed by facility Total $377.00 Project total $719 LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 48 Appendix B Pre-Post Tests Depression Basics Quiz 1. Depression is not a normal part of aging for older adults. It is a common medical condition that [can be treated] [has no treatment]. Depression is often [unrecognized] [noticed] and not treated in older adults. Depression is [a sign] [not a sign] of weakness, and you can [not] [just] "snap out of it." 2. What percentage of older adults in assisted living experience depression? a. Less than 1% b. Up to 35% c. 20% 3. What causes depression in older adults? (Choose all that apply) a. Low income b. Changes in social support c. Health problems d. Physical disability e. Family history or past personal history of depression f. News reports 4. What are some causes of depression that are specific to assisted living residents? (Choose all that apply) a. The layout or décor of the building b. No feeling of accomplishment c. The food served at the facility d. Lack of control over their own lives 5. What are the symptoms of depression in older adults? a. No interest in usual activities, sadness, lots of energy b. Changes in sleeping and eating patterns, low energy, sadness, loss of interest c. Feeling sad, being angry with family or staff, being focused on what they want to do d. Older adults have no specific symptoms of depression 6. The best treatment for depression in older adults is an antidepressant. Psychotherapy doesn't work well for them. a. True b. False Having the Conversation Quiz 1. Only the facility nurse and administrator can create a therapeutic relationship with a resident. c. True d. False LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 49 2. A therapeutic relationship has the following qualities (choose all that apply): a. You can create a relationship quickly b. The relationship promotes healing c. The relationship can provide support to the resident d. The relationship can help increase the resident's ability to function e. The relationship is short and requires no maintenance 3. Therapeutic communication is purposeful and seeks to understand and help the resident. Which of the following are involved in therapeutic communication? a. Body language, tone of voice, acceptance, empathy b. Giving directions, facial expressions, expecting compliance c. Expertise in health issues, life experience, respect 4. It is important to let the resident begin the conversation if you think they have depression symptoms. You should not ask them questions. a. True b. False 5. Non-verbal communication is the [most common] [least common] type of communication. 6. You might be the only person who asks the resident showing signs of depression if they feel OK. Choose all of the ways you can manage this conversation. a. Make judgemental comments about the situation b. Show compassion c. Keep the conversation respectful and natural d. Remind the resident that there is help available and encourage them to accept help e. Plan on only one conversation. Challenging Conversation Quiz 1. The signs of abuse and the symptoms of depression are similar. e. True f. False 2. Absolute confirmation of abuse [is] [is not] needed before reporting to adult protective services or local law enforcement. 3. Older adults in assisted living never experience suicidal thoughts and certainly never harm themselves, so we don't need to talk about it. a. true b. false 4. Risk factors for suicide include the following: a. Depression, physical disability, major life transition, financial problems b. Resilience, religious beliefs, family involvement c. Strong connections with staff, pleasant living environment, purposeful activities 5. If a resident is actively discussing suicide and has a method to harm themselves, you should find help and call 911. a. True b. False LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 50 6. Situations involving suspected abuse or suicide can be stressful for staff members and residents. These situations are more than one person can handle alone, and it is important to use good communication with the care team. Who are the members of the care team at your facility? a. The administrator b. The facility nurse c. Other CNAs d. Activities, housekeeping, and nutrition staff e. Resident's friends and family f. Clinicians (mental health and primary care providers) Behavioral Activation Quiz 1. Behavioral activation is a therapy where people talk about their feelings and understand how their past affects their moods today. a. True b. False 2. Behavioral activation involves the following steps (choose all that apply) a. Tracking daily activities b. Constant exercising to get stronger c. Reflecting on your values and choosing activities that match your values d. Writing all your feelings in a journal every day e. Selecting one activity at a time to incorporate into your routine and choosing someone to help and support you f. Behavioral activation is a treatment performed at the hospital 3. Depression can cause people to: a. Stop doing activities they enjoy b. Plan and carry out many goals c. Want to make changes in their lives 4. Residents may find out behavioral activation to be very [hard] [easy] and will [need] [not need] support from staff and family to accomplish their goals. 5. Behavioral activation is a process that is only completed once, and the resident is cured of their depression. a. True b. False Depression Screening Quiz 1. The GDS-15 can only be administered by a nurse. a. True b. b. False 2. Steps to take for adequate depression care include (choose all that apply): a. Screening the resident using a valid screening tool b. Ignoring suicidal statements so as not to encourage the resident in those thoughts c. Notifying primary care of screening results LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 51 d. Providing education and information about further treatment options e. Assessing cognitive function if there are concerns about cognitive decline 3. The GDS-15 can take thirty minutes to complete. a. true b. false 4. What score on the GDS-15 is suggestive of depression? a. More than 5 b. More than 10 c. More than 7 d. More than 2 5. The GDS-15 [is] [is not] a substitute for diagnosis by a mental health provider or a primary care provider. 6. The GDS-15 can also screen for suicide risk. a. True b. False Leading Behavioral Activation Quiz 1. The steps of behavioral activation include (choose all that apply): c. Monitor daily activities d. Reflecting on personal values e. Choosing an activity to try f. Choosing someone to assist them with their activity g. Exercising a lot more h. Ignoring their emotions 2. All behavioral activation class worksheets must be completely filled out without assistance. a. True b. False 3. It is OK to read the class scripts when you lead the group a. True b. False 4. Personal values include: a. Relationships, education, spirituality, responsibilities b. Income, winning bingo every time, having the best-decorated room c. Being popular and never feeling sick 5. The most important thing to remember is that behavioral activation group is voluntary. a. True b. False LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 52 Appendix C Facility Staff Survey Not important Slightly important Moderately important Very important Extremely important Before this training, I felt that depression treatment was an important part of resident health. 1 2 3 4 5 The steps of this process were important to increase residents' access to depression treatment. 1 2 3 4 5 Strongly Disagree Disagree Neither agree nor disagree Agree Strongly Agree I received adequate training to present the intervention to residents. 1 2 3 4 5 I felt confident in my ability to address difficult situations during this intervention. 1 2 3 4 5 The education materials and training modules were easy to use. 1 2 3 4 5 Never Rarely Sometimes Often Always This new process created a burden in the routine resident care process. 1 2 3 4 5 I will incorporate this process into the usual resident care routine. 1 2 3 4 5 LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 53 Appendix D Geriatric Depression Scale: Short Form Choose the best answer for how you have felt over the past week: 1. Are you basically satisfied with your life? YES / NO 2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 10. Do you feel you have more problems with memory than most? YES / NO 11. Do you think it is wonderful to be alive now? YES / NO 12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO 14. Do you feel that your situation is hopeless? YES / NO 15. Do you think that most people are better off than you are? YES / NO Answers in bold indicate depression. Score 1 point for each bolded answer. A score > 5 points is suggestive of depression. A score ≥ 10 points is almost always indicative of depression. A score > 5 points should warrant a follow-up comprehensive assessment. LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 54 Appendix E Resident Exit Survey Resident Survey Not at all Slightly familiar Moderately Familiar Very familiar Extremely familiar I am familiar with some causes and effects of depression. 1 2 3 4 5 I understand how to get treatment for depression. 1 2 3 4 5 Strongly Agree Agree Neither agree nor disagree Disagree Strongly disagree Learning to use behavioral activation skills is helpful to me. 5 4 3 2 1 The behavioral activation worksheets were easy to use. 5 4 3 2 1 I will continue to use behavioral activation for depression symptoms. 5 4 3 2 1 Never Rarely Sometimes Often Always I had support from the activity director. 1 2 3 4 5 I received help from facility CNAs. 1 2 3 4 5 LIFT UP, REACH UP: PROMOTING DEPRESSION CARE OF 55 Appendix F Project Timeline DNP Project TASK START COMPLETE Planning & IRB Submission Planning with WHS and Literature Review 1/1/21 8/9/21 Created materials for resident education 7/31/21 10/13/21 Weber State IRB application and approval 9/27/21 11/23/21 Utah Department of Health IRB application and approval 11/15/21 2/24/22 Created staff education materials 10/21/21 3/7/22 Collaboration with assisted living facilities 11/16/21 4/20/2022 Implementation ALF staff education 6/30/2022 8/31/2022 Resident assessment 7/5/2022 8/5/2022 Resident Group behavioral activation 9/7/2022 11/09/2022 Exit surveys 8/30/2022 11/09/2022 Evaluation Compile GDS-15 data to compare scores pre and post-implementation 11/09/2022 11/11/2022 Follow-up meeting with staff to discuss results 11/14/2022 11/15/2022 Complete project evaluation and dissemination 10/03/2022 11/16/2022