Community Partners in Care is a Research Project Funded by the National Institutes of Health

Underserved communities of color in low income, largely ethnic-minority neighborhoods face an excessive burden of illness from depression due to higher prevalence of depression and lower access to quality care. Evidence-based quality improvement (QI) programs for depression in primary care settings-where many low-income and minority patients receive their only mental health care-can enhance quality of depression care and improve health outcomes. These programs are under-utilized in community-based health care settings, and have not been adapted for use across diverse agencies (social service, faith based, primary and specialty care) that could partner to support disease management for depression. Partners in Care (PIC)and WE Care are interventions designed to improve access to evidence-based depression treatments (medication management or psychotherapy) for primary care patients and, in WE Care, social service clients. PIC evaluated a services delivery intervention while WE Care was an effectiveness trial with study-provided treatments. Both studies promoted use of the same evidence-based treatments. Both PIC and WE Care programs improved use of evidence-based treatments for depression and health outcomes for African Americans and Latinos. The PIC interventions reduced health outcome disparities evident in usual care in the first follow-up year and at five-year follow-up. While these findings offer hope to underserved communities, such communities have poor resources to support implementation of these programs, and may have historical distrust in research and health care settings. There is no evidence-based approach to support agency networks in underserved communities in implementing QI programs for depression. To address this information gap, investigators created Community Partners in Care (CPIC), a group-level randomized, controlled trial, with randomization at the level of an agency site or "unit." The trial is being fielded in two underserved communities, Hollywood and South Los Angeles, and conducted through a community- participatory, partnered research (CPPR) approach.

The specific aims of the study are:

• To engage two underserved communities in improving safety-net care for depression.
• To examine the effects of a community-engagement approach to implementing evidence-based depression quality improvement toolkits (PIC/WE Care) through a community collaborative network across services sectors, compared to technical assistance to individual programs from the same services sectors coupled with culturally-competent outreach to implement the same toolkits. The outcomes are: a) client access to care, quality of care and health outcomes, with the primary outcome being mental-health related quality of life and additional outcomes reflecting social determinants of mental health of interest to the community (physical health, homelessness risk factors, employment); b) services utilization and costs; c) agency adoption of PIC/WE Care; d) and provider attitudes, knowledge and practice.
• To describe the process of implementation of the community engagement intervention.

CPIC was awarded funds from the Patient Centered Outcomes Research Institute (PCORI) in 2013 to accomplish the following 3 aims:

• To compare the long-term (3-year) effectiveness of community engagement and planning versus agency technical assistance to implement depression QI and improve depressed clients' health status and risk for homelessness
• To determine how depressed clients in under-resourced communities prioritize diverse health and social outcomes and identify their preferences for services to address priority outcomes
• To identify capacities of providers to respond to depressed clients' priorities and to generate recommendations for building capacity to better address clients'priorities.

We hypothesize that community engagement and planning will be more effective than technical assistance in improving 3-year outcomes and that clients will prioritize quality of life. We expect to find gaps in provider capacities to address client priorities that network strategies could address.

Our primary outcome for the long-term follow-up is mental health related quality of life and secondary outcomes are use of healthcare and community services for depression and physical functioning and homeless risk factors.

In 2014, CPIC was awarded funds from the National Institute on Minority Health and Health Disparities (NIMHD) to use existing quantitative CPIC data and collect new qualitative data to describe pathways to reducing disparities. The funding allows us to longitudinally track the implementation of the CEP model in a new county-wide initiative to develop community networks to promote healthy neighborhoods. The aims under this additional funding are:

• To determine pathways to reducing mental health and social disparities by conducting community-academic partnered analyses of CPIC data by 1) examining intervention effects for disparity subgroups (African Americans, Latinos, gender groups, insurance and housing status groups); 2) identifying predictors and mediators of barriers to access/services and client outcomes; 3) analyzing intervention effects on provider workforce diversity; and 4) generating explanatory models for intervention effects and their sustainability by interviewing CPIC administrators and providers, as well as prior and current clients.
• To explore the generalizability and replicability of the CPIC partnered model and, more broadly, to inform the process of incorporating science into policy by conducting a longitudinal case study of the CEP model implementation in a county-wide "neighborhood health" initiative in Los Angeles to reduce mental health and social disparities.

As a result of this study, we will be able to explain how community-engaged and participatory models of intervention implementation can reduce health and social disparities and ultimately achieve public health impact. Study findings will be disseminated widely using traditional academic, community-valued, and policy-relevant dissemination channels.

Inclusion criteria

Administrators

• Age 18 and above
• Work or volunteer for an enrolled program in the study and be designated as a liaison by the program

Providers

• Age 18 and above
• Have direct contact with patients/clients

Clients

• Age 18 and above
• Score 10 or greater on modified Patient Health Questionnaire (PHQ-8)

Exclusion criteria

grossly disorganized by screener staff assessment Not providing personal contact information

Administrators - Under age 18

Providers

• Under age 18

Clients

• Under age 18
• Gross cognitive disorganization by screener staff assessment
• Providing no contact information