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Chapter 5. Rhode Island: Working toward Wellness
Introduction
This chapter will describe the Hard-to-Employ demonstration evaluation of Working toward Wellness (WtW). WtW is a telephone care management and outreach monitoring model designed to help low-income individuals who are experiencing major depression to enter and remain in evidence-based treatment. This study is targeted specifically to Medicaid recipients in Rhode Island who are eligible for mental health services through United Behavioral Health.1
This chapter begins with an overview of existing research on depression treatment, particularly for low-income individuals, discusses several studies of the effectiveness of various care management models, and explains why such interventions are relevant to policymakers and researchers in this field. The chapter continues with a description of the WtW intervention and the research design and procedures used in the evaluation. It presents the baseline characteristics of the sample members, followed by an outline of the key outcomes for the study’s participants and the data sources that will be used to track these outcomes. In addition, it summarizes the findings from the early assessment and analyzes the data on the sample members participating in the WtW intervention. The chapter concludes with an analysis of the preliminary results for a small number of sample members on use of behavioral health services.
Background and Policy Relevance
Research on public assistance recipients indicates that as many as one-quarter have experienced past-year depression.2 Moreover, their depression may be one of several barriers that limit their employability.3 Although a considerable body of random assignment research has identified various types of efficacious treatment for depression4 and indicates that “treatment for depression can reduce job loss and work-related impairments,”5 studies that are specifically applicable to low-income, hard-to-employ populations, in particular Temporary Assistance for Needy Families (TANF) recipients, are not yet available.
Despite considerable progress in the field of depression care, many depressed individuals fail to receive adequate treatment — with current estimates indicating that treatment rates among depressed individuals may be as low as one-fifth.6 In low-income communities, where knowledge of depression treatment and quality of care may be lower than in higher-income communities, even fewer people receive treatment. Moreover, even among those individuals who do seek treatment, relapse rates are quite high,7 suggesting the importance of strategies that maintain continuity of care.
One promising way to address this problem is through care management, which is designed to support clinical treatment by actively facilitating an individual’s engagement in treatment, with particular emphasis on the quality and continuity of that treatment. Six- and 12-month follow-up findings from Partners in Care, a randomized clinical trial that evaluated depression care management by nurses in primary care settings, suggest that intensive care management can decrease depression and unemployment.8 Five-year follow-up data suggest that the impacts on depression and other health outcomes are enduring.9 Moreover, Partners in Care appears to have been more effective among Latinos and African-Americans relative to whites. Other depression interventions10 have been successful in targeting the disadvantaged and minority populations that are of special interest to researchers and policymakers.
More specifically, a growing number of effectiveness trials indicate that telephonic care management programs provide a cost-effective approach to improving care for depression.11 Together, these studies have evaluated redesigned systems for the management of depression that include: (1) a telephone care management program with outreach calls; (2) an information system to monitor adherence and outcomes; (3) a system of consulting specialists or a computer support system; and (4) patient materials or self-management support (educational materials or psychoeducational interventions). Compared to usual care, these systematic interventions have led to improved clinical outcomes and patient satisfaction. Telephone approaches are also being tried in the management of other conditions, with varying degrees of success, for example, diabetes,12 asthma,13 and substance abuse.14
In addition, a study conducted by Simon and colleagues (2004)15 evaluated the effects of two intervention programs: telephone care management and telephone care management plus telephone psychotherapy. Overall, results of this study suggest that telephone-based outreach, medication monitoring, and brief, structured psychotherapy were well accepted by patients and significantly improved their clinical outcomes, compared with usual primary care. These findings suggest the value of a public health approach to psychotherapy for depression, including active outreach and vigorous efforts to improve access to and motivation for treatment.
Program Description
Recent studies have shown that there are many factors to consider in the design of enhanced care management outreach models targeted to traditionally underserved populations (such as those who are economically disadvantaged and racial and ethnic minorities). For example, they must effectively address cultural and language differences regarding health and health care, which can also make them more resource-intensive and costly. The potentially high costs of these outreach models and the high prevalence of depression among low-income individuals, particularly women, underline the need for an inexpensive and effective type of outreach.
WtW is a telephone care management intervention designed to help Medicaid recipients who are experiencing major depression seek and remain in evidence-based treatment. Individuals are being offered WtW only as part of the Hard-to-Employ evaluation. The care manager-outreach monitoring model was developed by researchers from Group Health Cooperative in Seattle, and is currently being evaluated among a working population in a large-scale study, Outreach and Treatment for Depression in the Labor Force, funded by the National Institute of Mental Health and led by a research team from Harvard Medical School. This study is known as the Workplace Depression Study for short.16
The WtW intervention has two phases: (1) recruitment into in-person treatment and (2) monitoring of in-person treatment. Recruitment begins when the care manager first calls the client and continues until the client’s first in-person visit with a therapist. Monitoring begins after the client’s first visit with a therapist and continues until the end of the 12-month intervention. Throughout the intervention, the care management is monitored for both its quality and its consistency. In addition, the care manager regularly administers the nine-item depression module of the Patient Health Questionnaire (PHQ-9)17 to track the severity of the client’s depression.
In general, the role of the care manager is to facilitate and support clinical treatment. More specifically, the care manager discusses possible treatments and medications with the client, continually assesses the client’s depression, and, if appropriate, encourages the client to seek in-person treatment. During the recruitment phase, care managers provide initial education regarding depression and depression treatment and try to motivate the client to receive treatment.
During the ongoing monitoring phase, care managers:
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monitor clinical and functional outcomes of treatment;
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monitor treatment adherence;
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provide feedback to treating clinicians regarding adherence to treatment and clinical outcomes;
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provide education and outreach to maintain adherence to treatment and prevent unplanned discontinuation of treatment; and
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facilitate appropriate follow-up care (including referrals to specialists).
In other words, once the client has begun in-person treatment, the care manager monitors her or his progress and attendance in therapy. Since failure to show up for an appointment is common among their clients, care managers frequently remind them to keep their appointments. The care managers will often follow up with their clients one or two days after their first appointment.
While traditional in-person treatment, including medication and/or psychotherapy, is recommended to clients, a structured telephone-based psychoeducational program (referred to as the “phone program”) is offered as a temporary alternative to treatment for clients who are unable or unwilling to engage in in-person treatment. The clients receive a workbook that contains didactic material, in-session exercises, and written homework exercises, which they are asked to complete before each phone session with the care manager. The workbook — which was developed by Group Health Cooperative staff and the care managers with the needs and experiences of the target population in mind — is a tool to encourage clients to start discussing the issues related to their depression, with the ultimate goal of getting them into in-person treatment. Therefore, while the clients are in the “phone program,” the care managers continue to discuss the option of in-person treatment.
Services are provided by one full-time and two part-time care managers, who are master’s-level clinicians who received training in outreach before the intervention began. Since some of their clients are Spanish-speaking, one of the part-time care managers is bilingual.
Research Design
The two main purposes of the study are to determine: (1) whether a telephone care management model focused on low-income parents can be successfully implemented and, if so, (2) whether the model is effective at alleviating depression, increasing employment and earnings, and reducing the use of public assistance. The study thus provides a unique opportunity to determine whether this relatively inexpensive type of outreach can be an effective model for state systems. In addition, this evaluation will also examine the effects of parents’ depression on the development of children and adolescents in low-income families and determine whether the intervention also benefits them.
A wealth of research has documented the negative effects of maternal depression on children’s development.18 Early studies found that children of depressed parents were at similar levels of risk as children of parents experiencing other forms of psychopathology, for example, schizophrenia.19 Children of depressed parents show decrements in social behavior and psychological functioning, as well as affective disorders, such as depression.20
The impacts of the WtW intervention are being assessed using a random assignment research design. Random assignment ensures that the groups are comparable when they enter the study and allows researchers to judge the likelihood that the program had an effect over time on, for example, employment rates or average earnings. For purposes of the evaluation, individuals who meet the study’s eligibility criteria (discussed further below) and appear to be depressed are randomly assigned to one of two groups:
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WtW group: Individuals in the WtW group receive intensive outreach from care managers, first to help them to enter treatment and then, if treatment begins, to remain in it for an appropriate time. Treatment is based on the American Psychiatric Association’s Evidence-Based Practice Guidelines for Major Depression, which includes psychotherapy and antidepressant medications. Outreach and care management takes place by telephone in order to reduce expense. In addition, WtW may have indirect effects on work-related outcomes if short-term improvements in depression subsequently lead to a greater interest and capacity to seek and retain employment.
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Usual Care (UC) group: UC group members are informed that they may be depressed and are given referrals to three mental health treatment providers in the community that provide Medicaid-covered services. If sought, the treatment would be the same as the standard behavioral health services generally offered by United Behavioral Health to its members. This “usual care” would not include access to intensive telephonic depression care management.
Since individuals were assigned to either the WtW or the UC group at random, any substantial differences that emerge between the groups can be attributed to the services provided by WtW. MDRC will continue to track the participants in each group for at least three and a half years. By following the two groups over time and comparing their mental health, employment, and other outcomes — such as welfare receipt — the study will determine the impacts of enhanced telephone-based care management for treating depression.
Random Assignment and the Sample Intake Process
The target population for the study includes Medicaid participants in Rhode Island who meet the following criteria: (1) They are of working age — 18 to 64 years old — and have children; (2) they appear to be experiencing major depression; and (3) they have selected the health plan option that makes them eligible to receive behavioral health care through United Behavioral Health.21 MDRC and United Behavioral Health decided to target a working-age population, because, in addition to its central focus on improvements in depression, this study is also going to test effects on employment. In addition, the criterion of having children is important, because this research is also concerned with the potential benefits to children of improvements in their parents’ well-being. Finally, eligibility to receive United Behavioral Health care is essential, given that the intervention is being offered by this company.
Individuals are excluded from the study if they appear to be at high risk for suicide, which is important, since these individuals require immediate crisis intervention.22 (Individuals who exhibit a high risk for suicide after they are enrolled remain in the study but are also referred for immediate assistance.) In addition, those suffering from bipolar disorder or mania, or alcohol or drug dependence, are also excluded because the presence of these conditions — even if they are occurring concurrently with major depression — could make them less responsive to this depression-specific intervention. Finally, because they are unlikely to be in need of the outreach being provided by the care managers, individuals who are actively engaged in treatment for depression are also excluded.
Figure 5.1 provides a detailed illustration of the study intake process, which involves several steps.
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Medicaid recipients eligible for services through United Behavioral Health are grouped into cohorts,23 which are randomly chosen by United Behavioral Health approximately every two and a half months.24 Cohorts were used so that participants would enter the study on a rolling basis, thus ensuring that the care managers maintain reasonable caseload sizes throughout the study.
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Potential study participants are mailed a letter describing the study and an initial “screener,” which includes the K6 and a few additional health-related questions.25 The K6 is a widely used, brief summary measure of nonspecific psychological distress that is comprised of six questions about mental health.26
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Care managers attempt to contact by telephone all individuals who return the completed screener and whose screener indicates an elevated risk for depression. If an individual is reached by telephone, the care manager will first ask permission to ask a set of questions about how the person is feeling. If the person consents, the care manager will administer the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR).27
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If the person’s responses indicate that she or he meets the criteria for depression,28 the care manager will explain the random assignment study and ask the individual if she or he agrees to take part in the research. If the individual agrees to be part of the study, the care manager asks for some additional sociodemographic, health- and child-related baseline information.
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The care manager then randomly assigns the individual via an Internet-based system to one of the two research groups: WtW or UC.
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Status of Random Assignment
In Rhode Island — at any given time — United Behavioral Health has a service-eligible membership of approximately 14,000 Medicaid recipients who are working-age adults with children.29 Based on a number of assumptions, it was projected that the study would recruit between 500 and 900 individuals — equally divided between the WtW and UC groups — by December 2005. However, by December 2005, only 280 total participants were enrolled in the study. Therefore, the intake period was extended through October 2006, which resulted in a final sample size of 507.
Considering its complexity, the sample intake process worked quite smoothly. However, a number of issues adversely affected sample build-up, as described below.
Low response rates to initial screener
Fewer people completed the initial screener than expected. The most optimistic projection assumed that 30 percent of potential participants would complete and return it, but response rates varied from 20 to 30 percent across the eight cohorts. Getting people to respond to this screener was somewhat more difficult than anticipated. Attempts to increase completion included:
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Sending additional mailings. United Behavioral Health started re-mailing the cover letter and screener approximately six months after the initial mailing. In general, the re-mailing most likely contributed to a higher response rate on the screener — after the re-mailing to Cohort 1, the response rate increased by 6 percent. The number of eligible study participants, however, increased only marginally. The main reason for this, discussed in more detail below, is inaccurate contact information.
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Calling people who do not complete the initial screener. For a brief time during the early stages of sample recruitment, the care managers attempted to contact by phone all individuals who had not returned a completed screener. Of the more than 200 “cold” calls the care managers made, only two individuals were successfully contacted and randomly assigned. Since the calls did not add much to the sample, the care managers discontinued them. Most of the calls were unsuccessful because the contact information, namely the phone numbers that came from United Behavioral Health’s administrative data, was inaccurate.
Outdated and inaccurate contact information
After people had responded to the initial screener, contacting them to administer the baseline interview was the next hurdle. One unanticipated problem was, again, that contact information was out of date. The evaluation team tried to address this problem in several ways:
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Identifying cohorts based on Medicaid eligibility date. Originally, United Behavioral Health chose the cohorts by selecting a random sample of people who met the eligibility criteria. This process was changed slightly, starting with Cohort 3, to randomly select people closer to their Medicaid application or re-determination date. The hope was that there would be more accurate contact information for people who had recently applied to Medicaid or had recently been re-determined as eligible for Medicaid.
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Revising the initial screener. The letter sent with the initial screener was also revised to clarify that contact information was required to activate the phone card incentive for responding. Specifically, multiple numbers were required for the incentive, as were the respondent’s preferences about when and where to call.
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Keeping cases with temporarily disconnected phone numbers “active.” The care managers regarded people with temporarily disconnected phone numbers as “active” cases, which meant they continued trying to contact them and did not classify them as having nonworking phone numbers.
High rate of decline
A total of 687 people met the criteria for depression on the QIDS-SR. Of those, 133, or 19 percent, declined to participate in the study. As a point of reference, the rate of decline in a similar randomized trial conducted by Simon and colleagues (2004) was 5 percent.30 This was also a test of telephonic psychotherapy and care management; however, it targeted individuals who were already engaged in some form of depression-related care. In addition, the research sample was drawn from enrollees in a large prepaid health plan in the state of Washington, whose membership is demographically similar to the Seattle-area population.
According to the care managers, people declined to participate in the Rhode Island study for one of two main reasons: (1) they did not have the time or (2) they did not think that they needed help. The care managers strongly encouraged people to participate in the study, but participation was voluntary. Therefore, although the study targeted a large number of individuals who are especially unlikely to seek depression treatment on their own, the sample might overrepresent — to some degree — people who were more likely to acknowledge that they needed help and were consequently more receptive to the possibility of engaging in care.
Characteristics of the Sample
United Behavioral Health care managers collected baseline data immediately following the administration of the QIDS-SR. The QIDS-SR is designed to determine whether the person meets the criteria for being diagnosed with major depression over the past seven days31 and is therefore eligible for the study. Data from the QIDS-SR are analyzed for the participants who are randomly assigned into the study. As part of the baseline survey, care managers also collect socio-demographic, employment, and prior treatment data, as well as data on participants’ children.
Table 5.1 shows the baseline characteristics of the sample. Data were analyzed for the total sample of 507 study participants. As expected, the characteristics of the two research groups were similar.
The majority of the participants (74 percent) had a total score on the QIDS-SR in the moderate to severe range at baseline, with an average score of 15. The average age of the participants was about 35. Approximately one-third (33 percent) of the participants were Hispanic. More than half the participants were either single or legally separated (57 percent) and were not living with a spouse or partner (61 percent).
Prior Treatment
One of the key outcomes of the WtW intervention is to get people into treatment. As shown in Table 5.1, the baseline measure for “ever received prior treatment from a professional” is relatively high (73 percent). This could mean that these participants are amenable to receiving treatment and might be more inclined to seek treatment than those who have never received treatment. However, of this 73 percent, only 39 percent (slightly more than half) received treatment within the past year. This may indicate that the problem of being unable to seek and remain in evidence-based treatment is not the result of a failure to recognize depression.
Children32
In order to qualify for the study, all participants must have a child. The average number of children per participant is two, and the average age of all children in the sample is 10 (see Table 5.2). A series of questions on the baseline survey asks specifically about one or two children per participant, called the “focal” children.33 These questions focus mainly on school and whether the children have conditions that might contribute to their parent’s depression and make it difficult to work. As Table 5.2 indicates, 76 percent of the study’s participants reported that their child’s health condition did not present a barrier to work or school. Most of the focal children did not have any physical, learning, or mental health conditions (69 percent) and had attended school in the past year (65 percent).
| Characteristic | Program Group | Control Group | Total | ||
|---|---|---|---|---|---|
| Total scores on QIDS-SRa (%) | Mild (6-10) | 11.5 | 15.4 | 13.4 | |
| Moderate (11-15) | 45.5 | 32.7 | 39.1 | ||
| Severe (16-20) | 31.2 | 38.6 | 34.9 | ||
| Very severe (21-25) | 11.9 | 13.4 | 12.6 | ||
| Average score on QIDS-SR | 15.2 | 15.6 | 15.4 | ||
| Sociodemographic characteristics | Gender (%) | Female | 88.9 | 90.6 | 89.7 |
| Male | 11.1 | 9.4 | 10.3 | ||
| Age (%) | 18-25 years | 15.8 | 10.6 | 13.2 | |
| 26-35 years | 34.8 | 43.7 | 39.3 | ||
| 36-45 years | 33.2 | 30.3 | 31.8 | ||
| 46+ years | 16.2 | 15.4 | 15.8 | ||
| Average age (years) | 35.4 | 35.4 | 35.4 | ||
| Race/ethnicity (%) | White, non-Hispanic | 44.3 | 47.2 | 45.8 | |
| Hispanicb | 34.4 | 31.5 | 32.9 | ||
| Black, African-American, non-Hispanic | 12.6 | 11.8 | 12.2 | ||
| American Indian or Alaskan Native | 2.0 | 3.1 | 2.6 | ||
| Asian or Pacific Islander | 1.2 | 0.0 | 0.6 | ||
| Other | 3.2 | 2.4 | 2.8 | ||
| Missing | 2.4 | 3.9 | 3.2 | ||
| Marital status (%) | Single, never married | 47.8 | 47.2 | 47.5 | |
| Married | 22.9 | 24.4 | 23.7 | ||
| Legally separated | 9.9 | 8.3 | 9.1 | ||
| Divorced | 17.0 | 17.3 | 17.2 | ||
| Widowed | 1.6 | 1.2 | 1.4 | ||
| Missing | 0.8 | 1.6 | 1.2 | ||
| Lives with spouse/partner (%) | Yes | 37.9 | 35.8 | 36.9 | |
| No | 60.5 | 61.8 | 61.1 | ||
| Missing | 1.6 | 2.4 | 2.0 | ||
| Average number of adults in household | 1.70 | 1.71 | 1.71 | ||
| Education (%) | GED certificate | 17.0 | 18.5 | 17.8 | |
| High school diploma | 34.8 | 36.6 | 35.7 | ||
| Technical/associate’s/2-year college | 17.4 | 12.2 | 14.8 | ||
| 4 years or more of college | 6.3 | 8.3 | 7.3 | ||
| None of the above | 23.7 | 22.4 | 23.1 | ||
| Missing | 0.8 | 2.0 | 1.4 | ||
| Currently employed (%) | Yes | 41.9 | 44.9 | 43.4 | |
| No | 54.5 | 53.1 | 53.8 | ||
| Missing | 3.6 | 2.0 | 2.8 | ||
| Number of months working on the current job (%) | Did not work | 58.2 | 54.9 | 56.5 | |
| 1 month or less | 4.2 | 2.5 | 3.3 | ||
| 1-6 months | 6.3 | 8.6 | 7.5 | ||
| 6-12 months | 7.2 | 9.0 | 8.1 | ||
| 12-24 months | 6.8 | 6.6 | 6.7 | ||
| More than 24 months | 17.3 | 18.4 | 17.9 | ||
| Average months working on the current job | 18.4 | 16.5 | 17.4 | ||
| Number of hours worked per week (%) | Did not work | 59.2 | 56.1 | 57.6 | |
| 10 hours or less | 2.1 | 2.9 | 2.5 | ||
| 10 to 20 hours | 3.4 | 8.8 | 6.1 | ||
| 20 to 30 hours | 8.6 | 7.9 | 8.3 | ||
| 30 to 40 hours | 23.6 | 20.9 | 22.2 | ||
| More than 40 hours | 3.0 | 3.3 | 3.2 | ||
| Average hours worked per week | 13.8 | 13.5 | 13.6 | ||
| Earnings per hour before taxes (%) | Did not work | 57.0 | 55.5 | 56.3 | |
| Less than $7 | 7.0 | 8.2 | 7.6 | ||
| $7-$9 | 11.2 | 12.2 | 11.7 | ||
| $9-$12 | 12.4 | 13.1 | 12.7 | ||
| $12-$15 | 7.0 | 6.1 | 6.6 | ||
| More than $15 | 5.4 | 4.9 | 5.1 | ||
| Average earnings per hour before taxes | 4.77 | 4.71 | 4.74 | ||
| Number of children per participant (%) | None | 2.4 | 1.6 | 2.0 | |
| 1 child | 39.5 | 40.9 | 40.2 | ||
| 2 children | 32.8 | 31.1 | 32.0 | ||
| 3 children | 17.8 | 17.3 | 17.6 | ||
| 4 children or more | 7.5 | 9.1 | 8.3 | ||
| Average number of children per participant | 1.9 | 2.0 | 2.0 | ||
| Prior treatment (%) | Ever received treatment from a professional | Yes | 75.1 | 70.1 | 72.6 |
| No | 24.5 | 29.1 | 26.8 | ||
| Missing | 0.4 | 0.8 | 0.6 | ||
| Received treatment within the past year | Yes | 43.9 | 34.6 | 39.3 | |
| No | 55.3 | 64.2 | 59.8 | ||
| Missing | 0.8 | 1.2 | 1.0 | ||
| Received antidepressant medication within the past year | Yes | 39.5 | 35.0 | 37.3 | |
| No | 59.7 | 63.4 | 61.5 | ||
| Don't know | 0.0 | 0.8 | 0.4 | ||
| Missing | 0.8 | 0.8 | 0.8 | ||
| Alcohol/drug use (%) | Has at least one alcoholic drink in a typical week | Yes | 29.6 | 29.9 | 29.8 |
| No | 33.6 | 31.9 | 32.7 | ||
| Missing | 36.8 | 38.2 | 37.5 | ||
| Use any type of recreational drugs in a typical month | Yes | 3.2 | 4.7 | 3.9 | |
| No | 42.7 | 43.7 | 43.2 | ||
| Missing | 54.2 | 51.6 | 52.9 | ||
| SSI/SSDI benefits (%) | Participant currently receiving SSI | Yes | 0.8 | 1.2 | 1.0 |
| No | 98.0 | 97.6 | 97.8 | ||
| Missing | 1.2 | 1.2 | 1.2 | ||
| Other household member currently receiving SSI | Yes | 13.0 | 10.2 | 11.6 | |
| No | 85.0 | 89.0 | 87.0 | ||
| Missing | 2.0 | 0.8 | 1.4 | ||
| Currently receiving SSDI | Yes | 2.0 | 2.8 | 2.4 | |
| No | 96.4 | 95.3 | 95.9 | ||
| Missing | 1.6 | 2.0 | 1.8 | ||
| Other household member currently receiving SSDI | Yes | 5.5 | 6.7 | 6.1 | |
| No | 92.9 | 91.3 | 92.1 | ||
| Missing | 1.6 | 2.0 | 1.8 | ||
| Sample size | 253 | 254 | 507 | ||
| SOURCE: MDRC calculations from Rhode Island baseline data for families randomly assigned from
November 17, 2004, to October 20, 2006. NOTES: In order to assess differences in characteristics across research groups, chi-square tests were used for categorical variables, and analysis of variance (ANOVA) tests were used for continuous variables. a QIDS-SR: Quick Inventory of Depressive Symptomatology-Self Report. b Sample member is coded as Hispanic if she/he answered "Yes" to Hispanic ethnicity. |
| Characteristic | Total | ||
|---|---|---|---|
| All children | Average age (years) | 9.6 | |
| Gender (%) | Male | 49.6 | |
| Female | 50.4 | ||
| Age group (years under 19) | 0-1 | 9.1 | |
| 2-3 | 8.8 | ||
| 4-5 | 9.8 | ||
| 6-7 | 11.1 | ||
| 8-9 | 12.5 | ||
| 10-11 | 12.3 | ||
| 12-14 | 16.3 | ||
| 15-18 | 20.2 | ||
| Average age of children under 19 years | 9.2 | ||
| Sample size | 987 | ||
| Focal children (%) | Has condition that presents barrier to work/school | Yes | 11.8 |
| No | 75.7 | ||
| Missing | 12.5 | ||
| Attended school in the past year | Yes | 65.0 | |
| No | 0.4 | ||
| Don't know | 0.4 | ||
| Missing | 3.2 | ||
| NA | 31.0 | ||
| Has any physical/learning/mental health conditions | Yes | 19.2 | |
| No | 69.4 | ||
| Don't know | 1.5 | ||
| Missing | 9.9 | ||
| Has received professional treatment for condition | Yes | 16.9 | |
| No | 71.5 | ||
| Missing | 11.6 | ||
| Sample size | 526 | ||
| SOURCE: MDRC calculations from Rhode Island baseline data for families randomly assigned from November 17, 2004, to October 20, 2006. NOTES: In order to assess differences in characteristics across research groups, chi-square tests were used for categorical variables, and analysis of variance (ANOVA) tests were used for continuous variables. |
Follow-Up Data Sources and Key Outcomes
The study will use several types of follow-up data to assess the impacts of the program:
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United Behavioral Health data. These data provide information on the eligibility and use of Medicaid services, such as behavioral and physical health care, and prescriptions for pharmaceuticals, for United Behavioral Health members only.
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TANF, food stamps, and Medicaid administrative data. These data, collected from the Rhode Island Department of Human Services (DHS), will include information on receipt of TANF, food stamps, and Medicaid benefits. The Medicaid data from the Rhode Island DHS will provide information on service receipt for all study participants.
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Sources of employment data. MDRC is currently looking to access wage data from the National Directory of New Hires. This is a national database maintained by the Office of Child Support Enforcement, and therefore would provide information on earnings from employment both within and outside Rhode Island.
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Survey data. The current research design for the WtW study includes three follow-up surveys: one at six months after random assignment; one at 18 months after random assignment to measure outcomes that cannot be assessed using administrative data; and one at 36 months after random assignment. The survey will obtain data on jobs not covered in unemployment insurance records; participation in outreach programs other than WtW; receipt of behavioral health services not covered in Medicaid claims data; outcomes on child well-being, depression, and other health outcomes; receipt of public assistance and social services; and material hardship.
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Case monitoring and tracking database. Group Health Cooperative maintains a live Web-based management information system (MIS) that provides comprehensive records on participation in WtW. The MIS is used to store information on clients’ participation in the intervention, as well as to track their treatment and progress over time, if applicable. Information is collected and entered by the care managers and monitored by the consultants at Group Health Cooperative, who make weekly calls to the care managers to review cases that are flagged by the database. (The MIS automatically flags cases with PHQ-9 scores of 15 or higher.) The weekly calls are also a way of monitoring and maintaining fidelity to the intervention’s design.
Early Findings from the Assessment
Sample Recruitment and Program Implementation
Generally random assignment worked properly and in accordance with its design. The complex, multistage, mail-out screening and assessment process identified the right population (working-age parents who received Medicaid and were experiencing major depression at baseline). In addition, the sample exclusion criteria were followed correctly.
Despite the complexities of the intake process, the required baseline data were collected. For the most part, the WtW and UC groups were similar at the time of random assignment.
Although the recruitment effort was quite extensive, the sample size fell short of the most optimistic projections. While the final sample of 507 will allow MDRC to detect impacts on depression that are similar in size to those found in other depression studies, the ability to analyze subgroups and detect effects on children will be constrained.
In addition, the WtW intervention is being well implemented with a high degree of fidelity to its design. The care managers are closely following the protocols for contacting and monitoring their cases and are also making intensive, ongoing efforts to encourage clients to participate in mental health treatment.
Contacts with Care Managers, Program Engagement, and Levels of Depression
Table 5.3 presents WtW group members’ participation in the intervention through the end of the sample intake period. The follow-up data range from three weeks to 12 months, depending on when the person began the intervention. These data represent all 253 WtW group members.
Of the 253 WtW group members, 237 (94 percent) have been contacted by a care manager, with an average of 6.9 contacts per person.34 In the study conducted by Simon and colleagues, of those assigned to telephone care management, 97 percent completed at least one telephone contact.35 However, this contact rate should be used as a reference rather than as a comparison, because the target populations of these studies differ considerably.
In addition, 47 percent of the WtW group members are currently — as of January 2007 — in the monitoring phase,36 and 25 percent are participating in the WtW phone program. The remaining 28 percent are not in treatment with a psychiatrist or a therapist. (These numbers are not shown in Table 5.3.)
Table 5.3 also shows WtW group members’ initial PHQ-9 scores, their most recent PHQ-9 scores, and the percentage improvement in PHQ-9 scores for 224 of the 253 group members.37 In general, depression severity scores for WtW group members have improved considerably since they began the intervention. Over three-quarters (76 percent) have shown some reduction in depression severity over time, and 40 percent of these had reductions in symptom severity of more than 50 percent. Only 24 percent have done worse over time; in other words, their most recent PHQ-9 score was higher than their initial PHQ-9 score when they started the intervention. It is important to remember that these depression results do not indicate whether the intervention has been effective, since follow-up data on depression for the UC group are not yet available.
Employment Status
As shown in Table 5.1, nearly half (46 percent) of the study’s participants were currently employed at the time the baseline survey was administered. According to Group Health Cooperative’s Case Monitoring and Tracking database, of the 237 WtW group members who have been contacted, a similar proportion (45 percent) are currently employed as of January 2007, based on their most recent contact with their care manager.
| Study Participants | Number | Percentage | ||||
|---|---|---|---|---|---|---|
| Total eligible for baseline interview per initial screener | 1,613 | |||||
| Total eligible who were contacted as of Oct. 20, 2006 | 1,119 | |||||
| Total meeting criteria per QIDS-SRa | 687 | |||||
| Total who agreed to participate and were randomly assigned | 507 | |||||
| Usual Care participants |
254 | |||||
| WtW participants | 253 | |||||
| Total WtW contacted by a care manager | 237 | 93.7 | ||||
| Average number of contacts per participant | 6.9 | |||||
| Initial PHQ-9 score (lowest to highest)b | 0-4 | NA | 5.4 | |||
| 5-9 | NA | 21.9 | ||||
| 10-14 | NA | 39.3 | ||||
| 15-19 | NA | 26.3 | ||||
| 20 plus | NA | 7.1 | ||||
| Most recent PHQ-9 score (lowest to highest)c | 0-4 | NA | 28.2 | |||
| 5-9 | NA | 28.6 | ||||
| 10-14 | NA | 26.7 | ||||
| 15-19 | NA | 10.2 | ||||
| 20 plus | NA | 6.3 | ||||
| Improvement in PHQ-9 scored | PHQ-9 score is worse than initially | NA | 23.8 | |||
| PHQ-9 score improved by 0-25 percent | NA | 17.0 | ||||
| PHQ-9 score improved by 26-50 percent | NA | 18.9 | ||||
| PHQ-9 score improved by more than 50 percent | NA | 40.3 | ||||
| SOURCE: Group Health Cooperative's case monitoring and tracking database for families randomly assigned from November 17, 2004, to October 20, 2006. NOTES: a Quick Inventory of Depressive Symptomatology-Self Report. 133 eligible people declined to participate in the study. b Patient Health Questionnaire. c Based on 148 WtW group members. |
Early Results on the Use of Behavioral Health Services
United Behavioral Health provided preliminary information on Medicaid use for 114 WtW and UC study participants receiving behavioral health services between November 17, 2004 (start of random assignment) and March 31, 2005. Table 5.4 presents these results by research group for two time periods: November and December 2004, and January through March 2005.38
The results are promising, albeit preliminary. When reviewing these data, keep in mind that the differences in service usage were not tested for statistical significance. Given the small sample sizes and the short follow-up periods, it is too early to determine whether the differences can be attributed to the WtW intervention.
The number of participants receiving outpatient care services is increasing for the WtW group (from 11 in November and December 2004 to 27 in January through March 2005), while the number remains the same for the UC group (10 in November and December 2004 and 9 in January through March 2005). Put differently, 48 percent (27 of 56) of the WtW group members received outpatient care services in January through March 2005, compared with 16 percent (9 of 58) of the UC group members. As listed in Table 5.4, outpatient services include treatment for substance (alcohol/drug) abuse, psychotherapy,39 medication evaluation, medication management, and medical outpatient services — that is, treatment by a primary care physician.
| Nov-Dec 2004 | Jan-Mar 2005 | ||||
|---|---|---|---|---|---|
| WtW Group | UC Group | WtW Group | UC Group | ||
| Level of care | Inpatient | 0 | 0 | 0 | 0 |
| Outpatient | 11 | 10 | 27 | 9 | |
| Type of outpatient care | Alcohol/drug services | 3 | 4 | 3 | 4 |
| Psychotherapy | 2 | 1 | 5 | 1 | |
| Medication evaluation | 4 | 2 | 7 | 1 | |
| Medication management | 0 | 1 | 1 | 2 | |
| Medical outpatient care | 2 | 2 | 11 | 1 | |
| Type of clinician | Psychiatrist | 1 | 1 | 5 | 1 |
| Psychologist | 2 | 0 | 1 | 0 | |
| Master's-level/other | 7 | 7 | 6 | 8 | |
| Medical doctor | 8 | 3 | 8 | 2 | |
| Sample size (total = 114) | 56 | 58 | |||
| SOURCE: Group Health Cooperative's case monitoring and tracking database. |
With regard to the type of outpatient care, the most notable differences are in psychotherapy, medication evaluation, and medical outpatient care. Looking at the period January through March 2005, one person in the UC group was in psychotherapy, compared with five in the WtW group; one person in UC was receiving medication evaluation, compared with seven in WtW; and one person in UC was receiving medical outpatient care, compared with eleven in WtW. These numbers suggest that the WtW group is more likely to receive these services, compared with the UC group. Furthermore, the WtW group is more likely to receive services from a psychiatrist (five WtW group members, compared with one UC group member) and/or a medical doctor40 (eight WtW group members, compared with two UC group members).
Conclusions
The Hard-to-Employ evaluation of the WtW intervention is the first study of a telephonic care management intervention targeted specifically to Medicaid recipients who are experiencing major depression. While there have been other studies of various types of care management models designed to help people who have various health and behavioral health needs, few have focused on getting them into in-person treatment for their depression. Working with low-income people who have significant — and sometimes multiple barriers to employment — presents additional challenges. For example, recruitment into the study and then subsequently into the intervention was complicated by the lack of accurate contact information. Despite these difficulties, the preliminary results suggest that participants in the WtW intervention may be experiencing an improvement in their depression and are more likely than those in the UC group to receive some form of psychotherapeutic treatment. These findings are promising and underscore the importance of this particular test and the need for more evaluation in this area.
1 WtW is being offered through United Behavioral Health, a managed behavioral health organization that has one of the largest Medicaid behavioral health caseloads in Rhode Island. (back)
2 Corcoran, Danziger, and Tolman (2003).(back)
3 Danziger et al. (1999). (back)
4 Katzelnick et al. (2000).(back)
5 Mintz, Mintz, Arruda, and Hwang (1992).(back)
6 Kessler et al. (2003).(back)
7 Belsher and Costello (1988). (back)
10 Miranda et al. (2006); Araya et al. (2003); Smith et al. (2002a and 2002b). (back)
11 Hunkeler et al. (2000); Katzelnick et al. (2000); Simon, VonKorff, Rutter, and Wagner (2000); Tutty, Simon, and Ludman (2000); Simon et al. (2004). (back)
12 Marrero et al. (1995); Schulz, Bauman, Hayward, and Holzman (1992). (back)
13 Pinnock et al. (2003). (back)
14 McKay et al. (2004). (back)
15 Simon et al. (2004). (back)
16 The model has been adapted for the WtW intervention, given the considerably different target population. Outreach and Treatment for Depression in the Labor Force is focused on active employees of large corporations, whereas WtW is focused on nondisabled Medicaid recipients. Nonetheless, both are based on telephonic outreach and care management for depression offered by master’s-level clinicians. (back)
17 Since WtW is a telephonic intervention, the PHQ-9 is administered by care managers over the phone. Levels of depression on the PHQ-9 range from 0 to 27, and are broken down into the following categories: 0-5 (none), 6-10 (mild), 11-15 (moderate), 16-20 (severe), and 21-27 (very severe). These levels parallel the levels assessed with the Quick Inventory of Depressive Symptomatology-Self Report measure and the Hamilton Rating Scale for Depression (HAM-D). See Kroenke, Spitzer, and Williams (2001). (back)
18 Weissman et al. (2006a and 2006b); Beardslee et al. (1997), Beardslee, Versage, and Gladstone (1998); Cicchetti and Toth (1998); Downey and Coyne (1990). (back)
19 Downey and Coyne (1990). (back)
20 See Cummings and Davies (1994); Downey and Coyne (1990); Goodman and Gotlib (1999, 2002) for reviews. (back)
21 Medicaid beneficiaries in Rhode Island who choose United Health Care (UHC) — one of the nation’s largest health plans — receive their basic health care through Americhoice, another health plan that partners with UHC. Members of Americhoice are then eligible to receive behavioral health care through United Behavioral Health, which partners with both UHC and Americhoice. (back)
22 These individuals — as indicated in Figure 5.1 — receive a “warm” transfer, which is when the participant is transferred directly from one counselor to another, without a disruption of the telephone connection. (back)
23 The term “cohort” has various definitions, depending on its context. For this evaluation, a “cohort” is a group of people identified at a specific point in time for study-related purposes. (back)
24 The study has a total of eight cohorts. (back)
25 Phone cards are mailed to all individuals with the screener and cover letter. Individuals who complete the initial screener — either by themselves or by phone with a United Behavioral Health care manager — have the phone card activated. Those who complete the remainder of the baseline survey will have $15 added to their phone card. (In an effort to expedite the pace of recruitment, the amount of the incentive was gradually increased over time.) (back)
26 See Kessler et al. (2002). The person must have a score of 13 or higher on the K6 to screen “positive” for likely depression and further assessment for potential participation in the research. The highest possible score on the K6 is 24. In addition, people who said they were ever told by a health professional that they were experiencing depression were screened positive and received further assessment. (back)
27 The QIDS-SR is designed to determine whether the person meets the criteria for being diagnosed with major depression over the past seven days. For more information on the QIDS-SR, see Rush et al. (2003). (back)
28 The person must have a score of 8 or higher on the QIDS-SR to be eligible for the study. The score on the QIDS-SR ranges from 0 (not depressed) to 25 (very severely depressed). The QIDS-SR is typically coded such that the scores range from 0 to 27. Adaptation of this instrument for telephonic administration by the Workplace Depression Study research team resulted in this change in the upper boundary of possible scores. (back)
29 According to United Behavioral Health, 77.5 percent of the adult Medicaid recipients they serve in Rhode Island are women. (back)
30 A total of 600 out of an eligible 634 (95 percent) agreed to participate in the study conducted by Simon et al. (back)
31 The QIDS-SR also allows for an assessment of depression severity over the past seven days. For more information on the QIDS-SR, see Rush et al. (2003). (back)
32 The data for children should be interpreted cautiously. Because of issues with baseline survey design and administration, the number of missing observations varies widely by measure. (back)
33 Focal children were identified at baseline, based on their age at that time. Up to two children per parent were identified as focal children. All focal children fell between the ages of 0 and 3 years old (Focal Child 1), or between the ages of 8 and 14 (Focal Child 2). Regarding the older group (8 to 14): Since there is special interest in youth between the ages of 10 and 13, children in that age range were prioritized over younger children as Focal Child 2. (back)
34 The median number of contacts was six. The number of contacts ranged from one to 27. (back)
35 Simon et al. (2004). (back)
36 This means that they are in treatment either with a psychiatrist or another mental health professional, such as a therapist. (back)
37 As of January 2007, the care managers had not been able to administer the PHQ-9 to 29 participants. (back)
38 For the November and December 2004 period, these claims data are complete, given that they reflect a sufficient time for all claims to have been submitted. However, the claims data for the period January through March 2005 are less complete. The data extracted for this analysis do not include data collected after March 2005, and therefore claims made after that time are not reflected here. The follow-up period for a Medicaid claim is typically three months after the claim was made. (back)
39 Psychotherapy can be received in a group or in an individualized setting, in a hospital, clinic, or office. (back)
40 Participants might see more than one type of clinician. For example, someone could be seeing a MD, as well as a master’s-level therapist, since some therapists cannot prescribe medication. (back)
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