Practice Concepts
The Gerontologist
Vol. 48, No. 6, 828–838

Copyright 2008 by The Gerontological Society of America

Healthy IDEAS: Implementation of a Depression
Program Through Community-Based Case
Management
Banghwa L. Casado, PhD, MSW,1 Louise M. Quijano, PhD, MSW,2
Melinda A. Stanley, PhD,3 Jeffrey A. Cully, PhD,3
Esther H. Steinberg, MSW,4 and Nancy L. Wilson, MA, MSW3

Purpose: Healthy IDEAS (HIDEAS; IDEAS stands for
Identifying Depression, Empowering Activities for Seniors) is an evidence-based depression program addressing commonly recognized barriers to mental health
care for older adults. The purpose of this study was to
describe the implementation of HIDEAS and assess its
feasibility. Design and Methods: Three community
agencies implemented the program with 94 eligible
older adults who were identified from 348 screened
older adults. We assessed program implementation by
using the Core Implementation Component framework,
using a client-tracking database, written survey of case
managers, focus-group interview with coaches, and
agency and project progress reports. Results: We
identified several challenges: clients’ reluctance to
This research was funded by a grant from the Administration on
Aging to Sheltering Arms Senior Services (Grant 90AM2812) and by
a subcontract with the National Council on Aging with funding from the
John A. Hartford Foundation of New York City. We recognize and
thank Catholic Charities, Harris County Social Services, and Sheltering
Arms Senior Services, whose steadfast commitment to the health and
well-being of older adults has made this demonstration project possible.
This research was supported in part by the Houston Center for Quality
of Care & Utilization Studies, Health Services Research and Development Service, Office of Research and Development, Department of
Veterans Affairs (Grant HFP90-020).
Address correspondence to Dr. Banghwa L. Casado, 525 West
Redwood St., Baltimore, MD 21201. E-mail: bcasado@ssw.umaryland.
edu
1
School of Social Work, University of Maryland, Baltimore.
2
School of Social Work, Colorado State University, Fort Collins.
3
Houston Center for Quality of Care & Utilization Studies, Baylor
College of Medicine, Houston, TX.
4
Care for Elders, Sheltering Arms Senior Services, Houston, TX.

828

acknowledge depressive symptoms and difficulty in
engaging in behavioral changes; differences among
case managers’ mental health knowledge, skills, and
‘‘buy-in’’ and difficulty managing limited time; and
differences in agency culture that foster in-agency
supervision. Implications: Successful adoption and
sustainability of HIDEAS are more likely when essential
elements of the Core Implementation Component
framework are addressed to bring about behavioral
changes at all treatment-implementation levels—clients,
practitioners, and organizations.

Key Words: Case management,
Community-based services, Elder depression,
Mental health intervention

Untreated depression is a major public health
concern, associated with impaired physical, mental,
and social functioning (U.S. Department of Health and
Human Services [DHHS], 1999), as well as increased
use of health services (Rowan, Davidson, Campbell,
Dobrez, & MacLean, 2002). Concerns are even greater
for older adults, especially minority and low-income
elders, who are underserved for mental health needs
(Alvidrez, Arean, & Stewart, 2004; Ojeda & McGuire,
´
2006). Clinical trials have shown that mental health
interventions are effective in treating depressive symptoms in older adults (Bartels et al., 2002; Cole &
Dendukuri, 2004; Roy-Byrne et al., 2003). However,
The Gerontologist

these interventions have not been widely adopted in
community agency settings because of a number of
challenges.
In a comprehensive review of the current literature,
Ell (2006) identified barriers to depression care for
older adults at all levels of treatment delivery—
patients, providers, and organizational systems. At
the patient level, older adults’ lack of knowledge about
mental illness and the stigma associated with mental
health care impede them from seeking mental health
services. At the provider level, health care providers’
lack of knowledge about late-life depression often
results in their failure to recognize it. Ell’s review also
suggests that insufficient training in depression care
may cause providers’ reluctance to assess and treat
mental health problems. This shortage of providers
with expertise in geriatric mental health care leads to
delayed recognition and detection of mental illness
among the elderly population. Additionally, organizational cultural differences among medical, mental
health, and social-service provider systems (Kilbourne
et al., 2004) and lack of coordination among them
(Bartels et al., 2002) hinder depression care for older
adults. Successful efforts to translate clinical evidence
and improve the quality and delivery of mental health
care for older adults will likely have to address these
barriers.
Healthy IDEAS (HIDEAS; IDEAS stands for Identifying Depression, Empowering Activities for Seniors),
a demonstration project of the Administration on
Aging Evidence-Based Disease Prevention Program, is
a community-based depression program delivered
through community agencies that offer a range of services for older adults. It targets the underserved lowincome, chronically ill older adults in the community
and addresses commonly recognized barriers to mental
health care: detecting depression; helping clients understand depression as treatable; assisting them to gain
knowledge and skills to self-manage it; and linking
primary care, mental health care, and social-service
providers. HIDEAS uses a unique approach in delivering depression care in that the entire intervention is
delivered, not by mental health professionals employed
solely to perform the intervention, but by case managers in existing social-service agencies who may or
may not have a prior mental health background. It is
designed so that all components of the intervention are
embedded into the ongoing assessment and care plan
routine of community case-management programs.
Our purpose in this article is to report a formal
evaluation of the HIDEAS implementation by using
the Core Implementation Component (CIC) framework proposed by Fixsen, Naoom, Blase, Friedman,
and Wallace (2005). The CIC framework, developed
from a synthesis of implementation research literature
published in the past 35 years, consists of six of ‘‘the
most essential and indispensable components’’ (p. 24)
of evidence-based program implementation: (a) staff
selection, (b) preservice and inservice training, (c) ongoing consultation and coaching, (d) staff and program
evaluation, (e) facilitative administrative support, and
(f) system interventions. Systems intervention involves
Vol. 48, No. 6, 2008

829

strategies in working with external systems to ensure
program sustainability through the securing of financial, organizational, and human resources. Although
plans for sustainability were part of the last phase
of the HIDEAS demonstration, insufficient time and
resources prevented collection of formal data on this
component. Therefore, this article reports the essential
elements and evaluation of the first five CIC framework
components of HIDEAS. Table 1 shows a description
of the CIC framework.

HIDEAS Program Overview
HIDEAS is an evidence-based program translated
and adapted from approaches tested in two randomized controlled trials treating depression in older
adults, namely, IMPACT (Unutzer et al., 2002) and
¨
PEARLS (Ciechanowski et al., 2004). It was implemented by a community–academic partnership and
delivered through case-management programs at three
social-service agencies (two nonprofit and one county).
Each agency directed all its employed case managers to
implement HIDEAS during routine duties. Table 2 shows
characteristics of agencies and their case-management
staff surveyed in this study. Faculty affiliated with
Baylor College of Medicine and the Houston Center
for Quality of Care & Utilization Studies provided
training, coaching, consultation, and program evaluation. HIDEAS participants included ethnically and
socioeconomically diverse community-dwelling older
adults at high risk for depressive symptoms. Table 3
summarizes participants’ characteristics.
A detailed overview of the program and evaluation
findings of successful client-level outcomes, including
reductions in depressive symptoms and pain and improvements in clients’ self-management skills, is available elsewhere (Quijano et al., 2007). Briefly, HIDEAS
consists of four components: (a) screening and assessment, (b) education, (c) referral and linkage, and (d)
behavioral activation. All existing and new clients
enrolled in case-management programs of participating
agencies at the time of recruitment (June 2004 to
December 2005) were asked to participate. Participant
inclusion criteria were being at least 60 years of age,
having the cognitive ability to participate and communicate verbally, and scoring 6 points or more on the
15-item Geriatric Depression Scale (GDS-15; Sheikh &
Yesavage, 1986).
During the demonstration project, case managers
approached 348 clients, screened them by using a twoitem depression-screen question from the Primary Care
Evaluation of Mental Disorders (Kroenke, Spitzer, &
Williams, 2003), and assessed them for depression by
using the GDS-15. Eligible clients (GDS-15 ! 6) and
their family members received education on depression
and printed materials. Case managers assisted clients to
communicate with a medical or mental health provider
to receive appropriate treatment. Behavioral activation
included written tools and focused on increasing
positive reinforcement in the clients’ environment by
helping them understand the link between mood and
actions and engage in fulfilling activities (pleasant

Table 1. Core Implementation Components and Evaluation Strategies
Core Implementation Component

Data Source

Staff selection
Identifying and recruiting qualifying practitioners and
organizations. Qualifications go beyond academic
background or experiences and include certain personal
characteristics and organizational culture, such as
willingness to learn new approaches.

Elements Assessed

Project progress reports
Case-manager survey
Coach focus group

Organizational prerequisites
Case-manager characteristics,
education, experiences,
professional scope

Agency reports
Case-manager survey
Coach focus group

Adequacy and helpfulness of
training and manuals

Ongoing consultation and coaching
A critical process in which the skills introduced in
training are learned and reinforced on the job for
adaptation with the help of consultation and coaching.

Case-manager survey
Coach focus group

Adequacy and helpfulness of
coaching

Staff and program evaluation
Program fidelity assessed for its context, compliance, and
competence. Context refers to prerequisites for program
operation, such as staffing, service–agency settings, and
prior training. Compliance and competence concern
how faithfully practitioners deliver the new program
as prescribed and how skillfully they do so, respectively.

Agency reports
Tracking records
Coach focus group
Case-manager survey

Context: Organizational setting,
scope, resources
Compliance: Delivery of intervention
components as prescribed
Competence: Ease or difficulty with
implementation

Case-manager survey
Coach focus group data
Agency reports

Adequacy of program leadership and
facilitation

Preservice and inservice training
An essential step for successful delivery of interventions
in which necessary background information and the key
components and rationale of the new program are
introduced to the practitioners, and interactive learning
opportunities are given to practice new skills and
techniques.

Facilitative administrative support
Providing leadership by making informed decisions,
supporting the implementation process, and maintaining
a focus on program outcomes.

events or simple accomplishments). HIDEAS components were incorporated into the routine case-management procedures and schedule of each participating
agency and delivered in 10 steps through face-to-face
visits in the clients’ homes and telephone contacts.
Table 4 summarizes the guidelines, actions, tools, and
resources used within each component.

Methods
Evaluation Strategies
We documented and evaluated HIDEAS program
implementation by using multiple methods involving
data collection from case managers, agency leadership,
and trainers or coaches.
Client-Tracking Data.—We used tracking data to
document delivery of the intervention. Using a written
tracking tool, case managers recorded contacts and
steps for each client. We then had recorded contacts
entered into a database to monitor and evaluate fidelity.
Figure 1 summarizes the tracking records, illustrating
delivery steps and rates as well as reasons for nondelivery at each step.
Case-Manager Survey.—Of 12 case managers, 10
completed an anonymous written survey at their
agency and mailed them to a designated evaluator (2
830

had departed from agency employment). We then
entered all data in an SPSS database for analysis. The
survey questionnaire asked case managers to rate six
areas of program implementation: program leadership
and facilitation, organizational context, professional
scope, effectiveness, client’s experience, and ease or
difficulty of implementation (Table 5). It also included
several open-ended questions asking case managers to
list benefits and challenges that they and clients
experienced. In general, responses were short and
specific. We had the written responses to these entered
in the database verbatim and had them transferred to
a spreadsheet for content analysis by using the analytic
strategy proposed by Stockdale (2002). Although
Stockdale’s strategy was originally proposed for the
analysis of focus group data, we found that the strategy
was also useful in the content analysis of case
managers’ responses. First, we entered the questions
and responses in separate columns of the spreadsheet
and sorted them by the questions. We reviewed the
responses and coded them for themes. We created
a column for each code identified, resulting in multiple
codes for some responses. We reviewed codes and
identified themes for four areas: benefits for case
managers, challenges for case managers, benefits for
clients, and challenges for clients.
Focus Group.—Using a semistructured interview
schedule, an independent evaluator not on the coaching
The Gerontologist

Table 2. Characteristics of Participating Agency and Case-Management Staff
Agency

Agency Description

Case-Management Staff Surveyed

Agency A

Nonprofit, multiservice agency
Founded 1893
200 full-time employees
Case management:
United Way-funded program
Eligibility: 60þ years, all incomes
Serves 272 clients annually

Agency B

Nonprofit multiservice agency
Founded 1943
257 full-time employees
Case management:
Provided through agency’s program for seniors
Eligibility: 65þ years, living alone, all incomes
Serves 105 clients annually

Agency C

County agency
420 full-time employees (human services
for all ages, settings)
Case management
Provided through assistance programs regarding
financial needs or financial representation
Eligibility: 60þ years, country residents, meet
income criteria Serves 1,630 clients annually

team conducted 1-hour focus-group interviews with all
coaches (N ¼ 6). This information was tape recorded
and transcribed verbatim by a research assistant.
Another independent evaluator then reviewed and
transferred the transcript to a spreadsheet for analysis,
using the same analytic strategy (Stockdale, 2002) used
in analyzing the responses of the case managers’ survey
just described. Themes identified in the focus group
were analyzed for three areas: coaches’ experiences
with coaching process, assessment of staff and agency
readiness, and intervention protocol.
Meeting Notes and Program Reports.—We reviewed meeting notes and program progress reports,
including those required by the funding source
(Administration on Aging), to document implementation activities, including training and agency qualityimprovement activities. Table 1 summarizes how we
used these data to assess each CIC of the HIDEAS
implementation.
The evaluation protocol of HIDEAS was reviewed
and approved as an exempt project by Baylor College
of Medicine and the University of Maryland, Baltimore
Institutional Review Boards.

HIDEAS Core Implementation Components and
Evaluation Results
CIC 1: Staff Selection
Because HIDEAS was designed to be delivered
through existing case-management services in the community, the selection of agencies to implement HIDEAS
was crucial, resulting in ‘‘automatic’’ determination of
Vol. 48, No. 6, 2008

831

Supervisor: Licensed master-level social worker
Case managers (n ¼ 4)
Education: 4 BSW
Average years working as a case manager:
10.1 years (range ¼ 1.5–30 years)
Average years working with older adults:
7.8 years (range ¼ 5–10 years) Average
caseload: 39 cases (range ¼ 35–45 cases)
Supervisor: Licensed master-level social worker
Case managers (n ¼ 3)
Education: 3 MSW (turnover in two positions)
Average years working as a case manager:
3.5 years (range ¼ 0.5–9 years)
Average years working with older adults:
2.8 years (range: 2.5 to 3 years)
Average caseload: 33 cases (range ¼ 25–37 cases)
Supervisor: Licensed master-level social worker
Case managers (n ¼ 3)
Education: 3 MSW
Average years working as a case manager: 2.6 years
(range ¼ 2.4–2.8 years)
Average years working with older adults: 3.1 years
(range ¼ 2.6–4 years)
Average caseload: 38 cases (range ¼ 11–70 cases)

individuals who would be delivering the intervention.
On the basis of a previous 9-month pilot of the program,
we developed the following criteria to identify agencies
with adequate capacity to implement it: (a) comprehensiveness and adequacy of the case-management program,
(b) ability to use standardized screening and assessment
tools, (c) capacity for linking to primary health care
and mental health providers, (d) adequacy of staffing for
agency caseload, and (e) commitment to addressing
depression in clients by adding an intervention. The
project lead and demonstration coordinator conducted
lengthy meetings with program leaders of seven different
agencies serving diverse populations. Ultimately, four of
these agencies satisfied the readiness and capacity
criteria; and three of these agreed to adopt the program
during the demonstration.
Twelve case managers delivered the intervention
during the project period. Case managers’ racial or
ethnic background was diverse, with three Caucasian,
five African American, two Hispanic, one Asian
American, and one biracial manager, reflecting the
clientele each agency was serving. All had either
a master’s degree (n ¼ 7) or bachelor’s degree (n ¼ 5)
in social work, with a mean of 5.8 years’ experience in
case management (SD ¼ 8.8, range ¼ 6 months to 30
years), and six managers reported some experience
providing mental health services. Mean years of
working with older adults was 4.8 (SD ¼ 2.9, range ¼
2.5–10 years). Average active caseload per worker was
37 cases (SD ¼ 15, range ¼ 11–70 cases; see Table 2).
Although survey results (Table 5) indicated that case
managers in general positively assessed their role in the
program (80%) and most agreed that HIDEAS was
within the scope of the agency (70%), coaches observed
variations in the skill level of workers, as well as

differences in agency culture that seemed to facilitate
or impede the worker–agency partnership in implementation. In the focus group, coaches reported that
agencies with ongoing and open communication
between case managers and their supervisor seemed
to be adaptive to the challenges of integrating a new
program in the existing case management. At the same
time, they sensed skepticism about mental health
interventions in a few case managers and spoke of the
challenge of gaining their ‘‘buy-in.’’

Table 3. Characteristics of Healthy IDEAS Clients
Screened (N ¼ 348) Eligible (N ¼ 94)

HIDEAS case managers needed to understand the
rationale for program components, as well as acquire
new skills for successful program delivery. To support
staff training, agency supervisors and case managers
received a detailed program manual and 12 hours’
interactive training over 2 days before implementation.
Training was conducted by academic mental health
professionals and included demonstration of skills and
opportunities for practice through role plays. To ensure
adequacy of training, we sought feedback from participants after each training session and addressed their
concerns during subsequent sessions. Whenever participating agencies hired new case managers, they were
individually trained, following standardized training
guidelines. Updates and booster training sessions were
given to all providers during project implementation
(two sessions, each a month apart after initial training;
and three additional sessions quarterly afterward) to
prevent ‘‘drift’’ in skills and address questions or
barriers that staff encountered.
In written reports, agency supervisors noted that the
program manual and training session were adequate
and helpful. Case managers agreed that training was
adequate (100%) and the manual helpful (80%; see
Table 5). In the focus group, coaches echoed that
preservice training was sufficient but recommended
that further emphasis on motivational interviewing
would enhance case managers’ ability to deliver the
intervention, especially the behavioral activation component, gain client buy-in, and reduce resistance.

%

n

%

Age (years)
60–64
65–74
75–84
85þ

52
104
132
60

14.9
29.9
37.9
17.2

23
35
25
11

24.5
37.2
26.6
11.7

Gender
Male
Female

CIC 2: Preservice and Inservice Training

n

84
264

24.1
75.9

20
74

21.3
78.7

Ethnicity
Caucasian
African American
Hispanic
Other

93
151
98
6

26.7
43.4
28.2
1.7

32
19
41
2

34.0
20.2
43.6
2.1

Marital status
Married
Widowed
Divorced or separated
Never married

54
185
67
41

15.6
53.3
19.3
11.8

22
38
23
11

23.4
40.4
24.5
11.7

Education
6 years
7–12 years
13þ years

77
179
70

23.6
54.9
21.5

21
45
24

23.3
50.0
26.7

Monthly income ($)
0–775
776–1,499
1,500þ

174
139
13

53.4
42.6
4.0

40
44
4

45.5
50.0
4.6

Living situation
Alone
With others

232
115

66.9
33.1

61
33

64.9
35.1

Primary language
English
Spanish
Other

275
71
2

79.0
20.4
0.6

58
35
1

61.7
37.2
1.1

Self-rated health
Poor or fair
Good or very good
Excellent

246
85
8

72.6
25.1
2.4

80
12
0

87.0
13.0
0.0

Characteristic

Note: For the age of screened clients, M ¼ 75.9, SD ¼ 9.5; for
eligible clients, M ¼ 72.5, SD ¼ 9.4. IDEAS ¼ Identifying Depression,
Empowering Activities for Seniors.

CIC 3: Ongoing Coaching
In HIDEAS implementation, a psychologist or social
worker from the academic partner provided coaching
to ensure fidelity of intervention delivery and address
individual needs for further training. Coaches and case
managers met twice a month for the first 3 months
and then once a month for up to 6 months for ongoing
coaching. Although the coaching model was integral
for program implementation, limitations existed
around how much coaches could monitor and supervise case managers. To create a sustainable and practicable approach to maintaining intervention fidelity,
coaches worked to transition the fidelity-monitoring
and support role to agency supervisors once an individual case manager demonstrated adequate understanding and skill in performing the intervention.
832

Most case managers (90%; see Table 5) agreed that
coaching was adequate and helpful. Coaches reported
that coaching was effective for developing case
managers’ skills and knowledge, as well as building
confidence. They saw their role as a clinical consultant
or resource for case managers, providing encouragement and guidance during implementation. Although
coaching was effective overall, coaches did find that
effectiveness was influenced by case managers’ attitudes
toward mental health interventions and that negative
attitudes made coaching more challenging. Coaches
used both individual and group coaching approaches;
they found the former beneficial for establishing trust
with case managers and the latter beneficial for mutual
The Gerontologist

learning and supportive process. Of particular importance for effective group coaching was open and
ongoing communications between agency supervisors
and case managers.

CIC 4: Staff and Program Evaluation
Context.—HIDEAS carefully selected implementing
agencies to ensure the context for success. Each community agency had a well-established case-management
program directly supervised by a master’s-level social
worker who welcomed partnering with academic and
mental health partners. All agency supervisors
agreed to embed HIDEAS steps in the existing casemanagement routine and to train all case managers to
implement the program.
When surveyed (Table 5), most case managers saw
HIDEAS within the scope of their agency (70%), and
they had enough resources to implement it (80%). They
expressed skepticism regarding the time required: more
than half (60%) thought it unrealistic as part of their
case-management duties. The results of focus-group
interviews indicated that although, in general, coaches
observed staff receptiveness to the new program, they
also recognized challenges related to time, especially
among case managers with a heavy caseload.
Compliance and Competency.—We used ongoing
coaching and a written tracking tool to monitor how
faithfully and skillfully each component was delivered
(see Frank, Coviak, Healy, Belza, & Casado, 2008, for
a description of monitoring strategies used to deliver
HIDEAS). Results of tracking records showed that the
delivery rate of each intervention component was
86.2% for education, 56.3% for referral and linkage,
and 44.7% for behavioral activation (Figure 1). Lower
delivery rates and a higher frequency of missing
documentation on the delivery, especially of the
referral–linkage and behavioral activation components,
were notable and reflected in challenges reported by
case managers with these two components. When asked
about ease or difficulty with intervention components
(Table 5), most case managers found screening
and education easy (90%), whereas only a half (50%)
and less than one third (30%) found referral and
linkage and behavioral activation components easy,
respectively.
In response to open-ended survey questions, case
managers listed challenges in helping clients engage in
behavioral activation activities. Challenges were both
attitudinal and technical. At the attitudinal level, case
managers noted clients’ lack of motivation and buy-in.
At the technical level, some clients had difficulty
identifying activity goals and following through with
them. The interview with coaches further accentuated
challenges with behavioral activation that some case
managers encountered. They observed that some case
managers were skeptical of the effectiveness of behavioral activation, possibly affecting their engagement in
implementation. At the technical level, they observed
that some case managers had difficulty engaging in the
Vol. 48, No. 6, 2008

833

client-directed approach involved in behavioral activation, in which clients select their own activities.
The most reported reason for nondelivery was
clients’ refusal to take further action about their
depressive symptoms (Figure 1), a major challenge
repeatedly reported by case managers and consistent
with other depression-treatment studies (Bruce, Wells,
Miranda, Lewis, & Gonzalez, 2002; Wetherell &
Unutzer, 2003). In written survey responses, several
¨
case managers noted a particular challenge related to
negative perceptions about mental illness in clients,
especially African Americans, making it difficult to
engage them in the intervention. Helping clients choose
and follow through behavioral activation activities was
also deemed a major challenge. Such difficulty among
case managers implementing behavioral activation was
also observed by coaches. Coaches also reported that
some case managers had difficulty with differences in
the helping process between behavioral activation and
traditional case management (the former emphasizing
a client self-help approach and the latter tending to be
task focused and more worker directed).
The HIDEAS model places additional time demands
on case managers, and many repeatedly reported this
to be a challenge. Survey results indicated that case
mangers spent, on average, 3.6 hours per client (SD ¼
2.5 hours) to deliver entire HIDEAS steps (Table 5). As
noted, 6 of 10 case managers found the time required
for HIDEAS, including added documentation, to be
unrealistic as part of their case-management duties.
Coaches observed this in a few case managers who saw
behavioral activation as an addition to their regular
duties. Although accurately measuring the exact time
needed to deliver all HIDEAS components is difficult,
reported time varied widely, ranging from 0.5 to 7
hours. This additional time, however, seems relatively
reasonable, given that delivery of HIDEAS components
was spread out over 10 or fewer steps over 3 months,
and the fact that some contacts could be by telephone.
Although time was a considerable challenge for many,
survey results indicate that most case managers agreed
that HIDEAS was easily implemented in other similar
case-management programs (70%) and that mental health
intervention should be part of case management (90%).

CIC 5: Facilitative Administrative Support
HIDEAS was implemented through a community–
academic partnership, with overall administrative coordination by Care for Elders, a partnership of public,
private, and nonprofit organizations focused on eldercare issues in Houston, Texas. Care for Elders
coordinated key activities: (a) facilitating training and
coaching for all three agencies, (b) conducting monthly
meetings of community agencies and academic partners, and (c) identifying additional resources to support
program implementation.
In the survey (Table 5), case managers gave high
marks to the lead and facilitation provided, with most
agreeing about the adequacy and helpfulness of
training (100%), training manuals (80%), coaching
(80%), and overall program facilitation (90%).

Table 4. Healthy IDEAS Overview of Steps
Component

Timing Guideline

Actions

Tools and Resources

Step 1: Screening
and assessment
of depressive
symptoms

Incorporate as part of
an initial client
assessment or a client
reassessment
In-person contact

Two-item question screen for
depression (PRIME-MD)
GDS-15
Suicide risk protocol
(if indicated)

Step 2: Education
on depressive
symptoms

Can be combined with
Step 1
In-person contact

Step 3: Referral,
linkage to
treatment

Refer and link clients
with GDS-15 score
!6; can be combined
with Steps 1 or 2
In-person or telephone
contacts

1. Ask two yes–no questions to determine
whether new or continuing clients may
be experiencing depressive symptoms.
2. Ask further questions of clients who
respond positively to determine severity
of clients’ depressive symptoms.
1. Review depressive symptoms with older
adult and family members or caregiver
(with permission).
2. Help older adults understand what they
can do to improve depressive symptoms
(self-care) and how family can help.
3. Explain what good depression care is.
1. Help clients obtain appropriate medical
treatment through interaction with
primary care provider or mental
health professional.
2. Address and overcome barriers where
possible.

Step 4 (BA):
Understanding
of BA

Begin within 2 weeks
of completing Step 2
for clients with
GDS-15 score !6
In-person contact
Within 2 weeks of
completing Step 4 (or
combine with Step 4)
In-person contact

1. Help clients understand the connection
between behavior and mood.

Step 6 (BA):
Reinforce
client

Contact within 1 week
of completing Step 5
In-person or telephone
contacts

1. Review depressive symptoms and
condition.
2. Review progress on all goals and
accomplishments.
3. Support client for progress made.

Step 7 (BA):
Maintain
contact

Complete contact within
2 weeks of Step 6
In-person or telephone
contacts

1. Review depressive symptoms and
condition.
2. Review progress on all goals and
accomplishments.
3. Support client for progress made.

Step 8 (BA):
Continue to
maintain
contact

Complete contact
within 2 weeks of
Step 7
In-person or telephone
contacts

1. Review depressive symptoms and
condition.
2. Review progress on all goals and
accomplishments. 3. Support client for
progress made.

Step 9:
Reassessment

Within 2 weeks of
Step 8 (usually 90
days from Step 1)
In-person contacts

1. Re-administer the Geriatric Depression
Scale.
2. Review accomplishments of goals.
Encourage client to maintain gains and
seek to attain new goals.
3. Review with supervisor and pursue
additional professional input for
clients with GDS scores above
6 who have not
been treated.

Step 5 (BA):
Setting goals
by reviewing
activities

1. Identify pleasant events and meaningful
activities; identify activities and steps to
promote well-being.
2. Coach client and family through
changing behaviors, taking action to
improve symptoms and achieve goals.

Written-materials: Handouts
and brochures
Depression: Don’t Let the
Blues Hang Around
Information for Families and
Friends About Depression
Pamphlet to help older adults
communicate information
to physician: Talking to
Your Doctor About
Depression
Inventory of local mental
health resources to
facilitate referrals
Follow-up communication to
primary care provider
Client-personalized forms:
Record Daily Activities
and Rate Mood
Client personalized forms:
Identify Pleasant Events
and Meaningful Activities
Identify Activities with
Steps You Can Take to Help
You Feel Better
List of Possible Activities
Tools for reinforcing
progress on goals:
Activity Planning and
Tracking Form
Consider Why Engaging in
Activity is Difficult
Tools for reinforcing
progress on goals:
Activity Planning and
Tracking Form
Consider Why Engaging in
Activity is Difficult
Tools for reinforcing
progress on goals:
Activity Planning and
Tracking Form
Consider Why Engaging in
Activity is Difficult
GDS-15
Use Step 5 tools for new
goals.

(Table 4 continues on next page)

834

The Gerontologist

Table 4. (Continued)
Component

Timing Guideline

Actions

Tools and Resources

Step 10:
Follow-up

Within 3 months of
Step 9
In-person contacts

1. Re-administer the GDS-15.
2. Review accomplishments of goals.
Encourage client to maintain gains
and seek to attain new goals.
3. Review with supervisor and pursue
additional professional input for
clients with GDS scores above 6.

GDS-15
Use Step 5 tools for
new goals.

Note: IDEAS ¼ Identifying Depression, Empowering Activities for Seniors; BA ¼ behavioral activation; GDS-15 ¼ 15-item Geriatric Depression
Scale; PRIME-MD ¼ Primary Care Evaluation of Mental Disorders.

Coaches in the interview also agreed that coaching was
effective in assisting case managers to gain knowledge
and skills, as well as develop self-efficacy and
confidence in mental health intervention.

Discussion
Use of the CIC framework to examine the implementation of HIDEAS has illuminated key issues and
challenges for agencies seeking to successfully replicate
this evidence-based depression intervention within
case-management programs. As demonstrated in this
study, assessing both organizational and individual
worker readiness and capacity to implement an
evidence-based intervention is critical. Although all
case managers trained to deliver the intervention were
assessed as being generally competent in skills to
deliver HIDEAS components, variability was documented in worker effectiveness in addressing barriers to
completing all program components, especially among
clients who needed encouragement and follow-through
to complete the intervention. Furthermore, some
agency supervisors were more effective than others
in helping workers address attitudinal and technical
barriers to successfully conducting the intervention. As
commonly noted in the literature on organizational
change, agencies seeking to implement evidence-based
programs have to carefully identify internal advocates
and champions who recognize the value and ‘‘essential
ingredients’’ of the intervention.
Our findings also underscore the importance of
training and ongoing consultation support involving
mental health expertise beyond what is available
through participating agencies. Because so-called external partners with a mental health background have
limitations as to how much they can monitor the
everyday business of agency staff, training and coaching have to include agency supervisors to encourage
and prepare them for within-agency supervision and
monitoring of program implementation.
Because the aim of HIDEAS is client self-management
of depression, it is imperative that case managers
understand and appreciate the value of a helping
process that encourages building client self-efficacy to
identify goals and take action. From our evaluation
with case managers and coaches, however, it was
apparent that some case managers struggled with the
Vol. 48, No. 6, 2008

835

client-directed selection of goals and activities of
behavioral activation and took a more directive
approach (setting goals and activities for clients) in
a manner used when services are being ordered to
meet an instrumental case-management need. Thus, the
importance of helping workers support client action
around goals that have meaning to them should be
addressed during preservice and inservice training, as
well as during ongoing consultation and coaching. On
the basis of lessons learned from this study, the
HIDEAS team produced a set of training tools,
including a training DVD, facilitators’ guide, and
improved program manual, to enable new agencies
and front-line providers to replicate the program (see
www.careforelders.org).
Key lessons regarding improvements to intervention
documentation and reduction of associated time
burden were also identified. The documentation required during the demonstration was independent of
other case-management record keeping and, as evident
in Figure 1, some case managers did not use the ‘‘extra’’
written tool to document implementation steps for
each client. Streamlining documentation requirements
and integrating tracking activities into routine casemanagement record keeping have been recommended
for future program implementation.
Even with a strong community–academic partnership, comprehensive information, and linkages to
available mental health resources in the community,
case managers still faced difficulties obtaining professional mental health care for some clients, especially
non-English-speaking clients without insurance. Although HIDEAS can be a feasible extension to the
existing health and mental health care continuum,
efforts must be made to enhance and secure adequate
mental health resources in the community that are
affordable and accessible to older adults.
Clearly, a major challenge in HIDEAS implementation was overcoming case managers’ discomfort and
lack of buy-in with behavioral activation. In the survey,
we found that many were uncertain about the effectiveness of behavioral activation and found it difficult.
This component required new skills and was the major
change in role for many case managers. It is interesting
to note, however, that although most case managers
found the implementation of behavioral activation
difficult, most also agreed that HIDEAS could be easily
implemented in similar case-management programs.

Figure 1. Flowchart of intervention components and delivery rates. The asterisks indicate that client contacts related to the
intervention were not documented by case managers; closed diamonds indicate that the delivery percentage was based on 94 clients
found eligible for Healthy IDEAS (IDEAS ¼ Identifying Depression, Empowering Activities for Seniors); the open diamond, others,
includes referrals to Adult Protective Services and a substance abuse counselor.

836

The Gerontologist

Table 5. Case Managers’ Survey Questions and Results
%
Questions

Agree

Program leadership and facilitation
Training for the Healthy IDEAS program adequately prepared me to do the
intervention.
The training manual was helpful in understanding and implementing the intervention.
My coach helped me to learn and implement the Healthy IDEAS intervention steps.
Questions and concerns about the Healthy IDEAS program were addressed adequately.

Neutral

Disagree

100
80
90
90

0
20
10
10

0
0
0
0

Organizational context
The Healthy IDEAS intervention is within the scope of my agency.
Agency resources supporting the Healthy IDEAS project were adequate.
Healthy IDEAS could easily be implemented in similar case management programs.
The time required for the Healthy IDEAS intervention was
realistic as part of my case-management duties.

70
80
70

20
10
20

10
10
10

30

10

60

Professional scope
Helping clients manage their depression is a part of my professional scope of work.
I feel comfortable providing the Healthy IDEAS intervention.
The Healthy IDEAS intervention fits in my role at the agency.
Mental health interventions should be a part of case management.

90
90
80
90

0
10
0
10

10
0
20
0

80

20

0

Effectiveness
The GDS worked well to identify clients with depressive symptoms.
Education helped to raise my clients’ awareness of and understanding about
depression.
Referring and linking my clients to other providers helped me to address my clients’
mental health needs.
The behavioral activation steps helped reduce my clients’ depressive symptoms.
Overall, the Healthy IDEAS intervention helped clients manage their depression.

70

30

0

80
40
50

10
60
40

10
0
10

Client’s experience
Overall, my clients were pleased that depression screening and assistance with
depression were offered as part of case management.

40

40

20

70
80
50
40

20
10
10
30

10
10
40
30

As the result of the depression education, my clients were able to do the following:
Identify depressive symptoms.
Understand ways to cope, prevent, and get help for depression.
My clients followed through with the recommended referrals for depression treatment.
My clients were able to make behavior change(s) to manage depression.

%
Easy
Implementation ease and difficulty
In general, how easy or difficult was it to do the following:
Administer the GDS?
Provide education about depression?
Refer or link clients to health and mental health providers?
Carry out the behavioral activation steps?
Do follow-ups?

Routine

Difficult

90
90
50
30
30

10
10
20
0
30

0
0
30
70
40

Note: For case managers’ survey questions and results, N ¼ 10. All questions used a 5-point Likert scale (1 ¼ strongly disagree, 2 ¼ disagree, 3 ¼
neutral, 4 ¼ agree, and 5 ¼ strongly agree; or 1 ¼ very difficult, 2 ¼ somewhat difficult, 3 ¼ routine, 4 ¼ somewhat easy, and 5 ¼ very easy). IDEAS
¼ Identifying Depression, Empowering Activities for Seniors; GDS-15 ¼ 15-item Geriatric Depression Scale. For the column headings, note that
Agree, Disagree, Easy, and Difficult each include two possible answers (strongly agree and agree, strongly disagree and disagree, very or somewhat
easy, and very or somewhat difficult). The questionnaire also asked the following question: On average, how much time was required to complete
the entire Healthy IDEAS intervention with a client who had a positive GDS score? The range was 0.5–7.0 hours (M ¼ 3.6, SD ¼ 2.5).

Although, from data we have, we cannot draw a
conclusion about the capacity of each case manager to
deliver behavioral activation, our study suggests that
paying careful attention to the potential of individual
providers, both in agency selection at the beginning and
Vol. 48, No. 6, 2008

837

in within-agency staff selection, may be crucial for
successful implementation of the program.
Other barriers in implementing HIDEAS were
consistent with those in the literature—negative
attitudes and skepticism toward mental health care

and reluctance to acknowledge or address depression
among older adults (Ell, 2006). Although those who
chose to participate saw improvement in their depressive symptoms (see Quijano et al., 2007), case
managers repeatedly noted clients’ refusals and reluctance to engage in the intervention, especially
African Americans. It is possible that this reluctance
might have contributed to the visibly low prevalence
of depressive symptoms found among our African
American clients, compared with our Caucasian and
Hispanic clients (13% of African Americans scored !6
on the GDS-15, vs 34% and 42% for Caucasians and
Hispanics, respectively). Given the persistent findings
of negative attitudes toward mental health care
(DHHS, 1999), multicultural approaches to delivering
the intervention are needed in program training. For
example, clients unwilling to acknowledge depression
might be willing to do something to help feelings of
pain. Perhaps religious advisors can be enlisted to
support a client’s taking action to feel better. Helping
older adults recognize their ability to take action to feel
better is necessary for successful implementation of the
intervention.
The essence and challenge of implementation are
bringing about behavioral changes in consumers, practitioners, and organizations (Fixsen et al., 2005), and
our study identified several such challenges. Despite
challenges, the outcome study has demonstrated that
HIDEAS is an effective evidence-based psychosocial
intervention for depression in older adults (Quijano
et al., 2007); and in written survey responses, case
managers also reported that HIDEAS helped clients
increase their knowledge of mental health issues and
gain skills to self-manage depression. We believe that
HIDEAS is a model for dissemination of effective
evidence-based psychosocial interventions for depression and could be successfully adopted and sustained
when essential elements of the CIC are addressed to
bring about behavioral changes at all implementation
levels.

References

Alexopoulos, G. S., et al. (2002). Evidence-based practices in geriatric
mental health care. Psychiatry Services, 53, 1419–1431.
Bruce, M. L., Wells, K. B., Miranda, J., Lewis, L., & Gonzalez, J. J. (2002).
Barriers to reducing burden of affective disorders. Mental Health
Services Research, 4, 187–197.
Ciechanowski, P., Wagner, E., Schmaling, K., Schwartz, S., Williams, B.,
Diehr, P., et al. (2004). Community-integrated home-based depression
treatment in older adults: A randomized controlled trial. Journal of the
American Medical Association, 291, 1569–1577.
Cole, M. G., & Dendukuri, N. (2004). The feasibility and effectiveness of
brief interventions to prevent depression in older subjects: A systematic
review. International Journal of Geriatric Psychiatry, 19, 1019–1025.
Ell, K. (2006). Depression care for the elderly: Reducing barriers to evidence
based practice. Home Health Care Services Quarterly, 25(1–2), 115–148.
Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F.
(2005). Implementation research: A synthesis of the literature (FMHI
Publication 231). Tampa, FL: University of South Florida, Louise de la
Parte Florida Mental Health Institute.
Frank, J. C., Coviak, C. P., Healy, T. C., Belza, B., & Casado, B. L. (2008).
Addressing fidelity in evidence-based health promotion programs for
older adults. Journal of Applied Gerontology, 27, 4–33.
Kilbourne, A. M., Schulberg, H. C., Post, E. P., Rollman, B. L., Belnap, B. H., &
Pincus, H. A. (2004). Translating evidence-based depression management
services to community-based primary care practices. The Milbank
Quarterly, 82, 631–659.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2003). The Patient Health
Questionnaire – 2: Validity of a two-item depression screener. Medical
Care, 41, 1284–1292.
Ojeda, V. D., & McGuire, T. G. (2006). Gender and racial/ethnic differences
in use of outpatient mental health and substance use services by depressed
adults. Psychiatric Quarterly, 77, 211–222.
Quijano, L. M., Stanley, M. A., Petersen, N. J., Casado, B. L., Steinberg,
E. H., Cully, J. A., et al. (2007). Healthy IDEAS: A depression
intervention delivered by community-based case managers serving older
adults. Journal of Applied Gerontology, 26, 139–156.
Rowan, P. J., Davidson, K., Campbell, J. A., Dobrez, D. G., & MacLean,
D. R. (2002). Depressive symptoms predict medical care utilization in
a population-based sample. Psychological Medicine, 32, 903–908.
Roy-Byrne, P. P., Sherbourne, C. D., Craske, M. G., Stein, M. B., Katon, W.,
Sullivan, G., et al. (2003). Moving treatment research from clinical trials
to the real world. Psychiatric Services, 54, 327–332.
Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric Depression Scale (GDS):
Recent evidence and development of a shorter version. Clinical
Gerontologist, 5(1–2), 165–173.
Stockdale, S. S. (2002). Analyzing focus group data with spreadsheet.
American Journal of Health Studies, 18, 55–60.
Unutzer, J., Katon, W., Callahan, C. M., Williams, J. J. W., Hunkeler, E.,
¨
Harpole, L., et al. (2002). Collaborative care management of late-life
depression in the primary care setting: A randomized controlled trial.
Journal of the American Medical Association, 288, 2836.
U.S. Department of Health and Human Services. (1999). Mental health: A
report of the Surgeon General. Rockville, MD: Author. Retrieved May
30, 2007, from http://www.surgeongeneral.gov/library/mentalhealth/
home.html
Wetherell, J. L., & Unutzer, J. (2003). Adherence to treatment for geriatric
¨
depression and anxiety. CNS Spectrums, 8(12 Suppl. 3), 48–59.

Alvidrez, J., Arean, P. A., & Stewart, A. L. (2004). Psychoeducation to
´
increase psychotherapy entry for older African Americans. American
Journal of Geriatric Psychiatry, 13, 554–561.
Bartels, S. J., Dums, A. R., Oxman, T. E., Schneider, L. S., Arean, P. A.,
´

Received January 19, 2008
Accepted June 11, 2008
Decision Editor: Kathleen Walsh Piercy, PhD

838

The Gerontologist