A Helping Hand Among Low-Income Patients

Major depression, plus other chronic illness such as diabetes, coronary heart disease and
heart failure is common among low-income, culturally diverse safety net care patients.
Unfortunately, many of these patients are uncomfortable about either asking their doctor
questions about their illness and treatment options and their illness self-care or informing
their doctors about their treatment preferences. Lack of strong engagement with medical
providers occurs because patients believe they lack the knowledge to ask questions or to
understand and follow recommended self-care and their concern that their medical provider
lacks understanding of their treatment preferences. These factors often result in patient
worry, poor adherence to prescribed treatment, and worsening illness status and even early
death. The study will be conducted by a university, the Los Angeles County Department of
Health Services (DHS) and a community health worker organization research team. The study
will be conducted within two DHS Patient-Centered Medical Home clinics, with each patient
having a designated primary care team of physician, nurse, social worker and medical
assistant. Study patients with major depression and other illnesses face numerous self-care
management barriers: managing concurrent symptoms (depression, pain, anxiety etc.) and
cultural influences (depression stigma, diet), difficulty in navigating primary and
specialty doctor and treatment plans, while at the same time experiencing daily social and
economic stress. The randomized comparative effectiveness study will recruit 350 patients
with major depression and a concurrent chronic illness (i.e., diabetes, heart failure,
coronary heart disease) from two DHS PCMH community health centers. To enhance
patient-centered research community partnerships, patients will be provided A Helping Hand
(AHH) in which a community organization- based promotora aims to activate patient-centered
depression self-care training and practical assistance to: a) improve and personalize major
depression self-care (e.g., medication or psychotherapy preference, treatment adherence,
fatigue, pain, diet, activity, stress management, family/caregiver communication); b)
activate patient-provider communication, clinic appointment keeping and treatment
coordination; and c) and facilitate patient navigation and receipt of needed community
resources. AHH aims to improve patient self-care management and patient-provider care
management relationships among underserved low-income patients, who must simultaneously cope
with major depression and chronic co-morbid physical illness. Study objectives aim to
determine: 1) whether community health worker promotora care management training improves
patient-centered outcomes, such as self-care need and management, treatment adherence,
symptom improvement, and care satisfaction over the usual team care; 2) depression symptom
improvement; and 3) patient hospitalizations and ER visits frequency.

Inclusion Criteria:

- age >18 years, have a phone, meet PHQ-9 score of 10 or more, and have concurrent
diabetes, CHD, or HF.

Exclusion Criteria:

- current suicidal ideation,inability to speak either English or Spanish fluently, a
score of 2 or greater on the CAGE 4M alcohol assessment,recent use of lithium or
antipsychotic medication, and cognitive impairment precluding informed consent.