Community-Based Outreach and Treatment for Underserved Older Adults With Clinically Significant Worry: A Randomized Controlled Trial.

OBJECTIVE: To determine whether Calmer Life (CL) improved worry, generalized anxiety disorder-related (GAD-related) symptoms, anxiety, depression, sleep, trauma-related symptoms, functional status, and quality of life better than Enhanced Community Care with Resource Counseling (ECC-RC) at 6 months and 9 months. METHODS: A randomized, controlled, comparative-effectiveness study involving underserved, low-income, mostly minority neighborhoods in Houston, Texas, looked at individuals ≥50 with significant worry and interest in psychosocial treatment. Interventions were CL, cognitive behavioral therapy with resource counseling, facilitation of communication with primary care providers about worry/anxiety, integration of religion/spirituality, person-centered skill content and delivery and nontraditional community providers, ECC-RC, and enhanced standard community-based information/ resource counseling addressing basic unmet and mental health needs. Primary outcomes were worry and GAD-related symptom severity. Secondary outcomes were anxiety, depression, sleep difficulties, trauma-related symptoms, functional status, quality of life, service use and satisfaction. RESULTS: Similar, moderate improvements followed CL and ECC-RC on worry, GAD-related symptoms, anxiety, depression, sleep, trauma-related symptoms, and mental health quality of life at 6 and 9 months, but with symptoms at both times and higher satisfaction with CL at both. Fewer ECC-RC participants reported a hospital admission in the prior 3 months than those in CL at 6 and 9 months; at 9 months, fewer reported a visit with a provider in the previous 3 months. CONCLUSION: Both interventions showed similar improvements at 6 and 9 months, but symptoms remained that might require care. Either intervention or a combination may be useful for low-income older adults with identified worry/anxiety.

Negative Consequences of Family Caregiving for Veterans With PTSD and Dementia.

Recent research shows veterans with posttraumatic stress disorder (PTSD) are twice as likely as other veterans to develop dementia. However, no studies to date have examined the impact of co-existing PTSD and dementia on family caregivers, who provide the majority of care to these veterans. Using the Stress Process Model, the current investigation explored the similarities and differences in psychosocial, health, and service use outcomes among caregivers assisting veterans with PTSD and dementia compared with caregivers assisting veterans with dementia only. Caregivers of veterans with PTSD and dementia indicated that their relative exhibited more difficult behavior symptoms and used more community services. These caregivers also reported more difficulties understanding veterans' memory problems and more physical strain. Together, results suggested caregivers of veterans with both PTSD and dementia were at greater risk of negative caregiving consequences. Implications and suggestions for future research are discussed.

Expanding the geriatric mental health workforce through utilization of non-licensed providers.

OBJECTIVES: We evaluate policy and practice strategies for bolstering the geriatric mental healthcare workforce and describe costs and considerations of implementing one approach. METHOD: Narrative overview of the literature and policy retrieved from searches of databases, hand searches, and authoritative texts. We identified three proposed strategies to increase the geriatric mental healthcare workforce: (1) production of more geriatric mental health providers; (2) team-based care; and (3) non-licensed providers. We evaluate each in terms of challenges and potential and provide estimates of costs, policy, and practice considerations for training, employing, and supervising non-licensed mental health providers. RESULTS: Use of non-licensed providers is key to reforms needed to allow a more older adults to access necessary mental healthcare. Licensed and non-licensed providers have achieved similar improvements for generalized anxiety disorder among patients, although non-licensed providers did so at a lower cost. CONCLUSION: Supervised non-licensed providers can extend the reach of licensed providers for specific mental health conditions, resulting in lower costs and increased number of patients treated. Although several barriers to implementation exist, policy and infrastructure changes that may support this type of care delivery model are emerging from reforms in financing and associated delivery initiatives created by the Affordable Care Act.

Telephone-Delivered Cognitive-Behavioral Therapy for Older, Rural Veterans with Depression and Anxiety in Home-Based Primary Care.

OBJECTIVES: Rural, homebound older adults are at increased risk for anxiety and depression and have limited access to mental health services. These individuals face many barriers to receiving evidence-based mental health treatment and would benefit from interventions that increase access to and efficiency of care. The aim of this study was to evaluate use of a telephone-delivered, modular, cognitive behavioral therapy (CBT) intervention for both late-life depression and anxiety delivered to rural, homebound Veterans. METHODS: Three cases are presented to illustrate the flexible adaptation of the intervention for use among older Veterans enrolled in home-based primary care, with varying symptom presentations and functional limitations. The Veterans received 7 to 9 sessions of the CBT intervention, with ordering of skill modules based on symptom presentation and determined collaboratively between patient and therapist. RESULTS: The three Veterans showed improvement in depression and/or anxiety symptoms following treatment and provided positive feedback regarding their experiences in this program. CONCLUSIONS: These results suggest that telephone-delivered CBT is acceptable to older adults and can be tailored to individual patient needs. CLINICAL IMPLICATIONS: Clinicians should consider telephone-delivered CBT as an alternate mode of therapy to increase access to mental health care for rural, homebound individuals with depression and anxiety.

Predictors of change in quality of life in older adults with generalized anxiety disorder.

BACKGROUND: Quality of life (QOL) is lower in older adults with generalized anxiety disorder (GAD). QOL generally improves following cognitive-behavioral treatment for GAD. Little is known, however, about additional variables predicting changes in QOL in older adults with GAD. This study examined predictors of change in QOL among older participants in a randomized clinical trial of cognitive behavioral therapy (CBT) for GAD, relative to enhanced usual care (EUC). METHODS: Hierarchical multilevel mixed-model analyses were used to examine inter-individual and intra-individual factors that predicted QOL over time. Predictors were categorized into treatment, personal and clinical characteristics. RESULTS: QOL improved over time, and there was significant variability between participants in change in QOL. Controlling for treatment condition, baseline general self-efficacy, baseline social support, within-person variation in worry and depression and average levels of depression across different time points predicted changes in QOL. CONCLUSIONS: QOL has increasingly been used as an outcome measure in treatment outcome studies to focus on overall improvement in functioning. Attention to improvement in symptoms of depression and worry, along with psychosocial variables, such as social support and self-efficacy, may help improve QOL in older adults with GAD. This study was a secondary study of data from a randomized clinical trial (NCT00308724) registered with clinical.trials.gov.

Making and Executing Decisions for Safe and Independent Living (MED-SAIL): development and validation of a brief screening tool.

OBJECTIVES: Older adults prefer to remain in their own homes for as long as possible. The purpose of this article is to describe the development and preliminary validation of Making and Executing Decisions for Safe and Independent Living (MED-SAIL), a brief screening tool for capacity to live safely and independently in the community. DESIGN: Prospective preliminary validation study. SETTING: Outpatient geriatrics clinic located in a community-based hospital. PARTICIPANTS: Forty-nine community-dwelling older adults referred to the clinic for a comprehensive capacity assessment. MEASUREMENTS: We examined internal consistency, criterion-based validity, concurrent validity, and accuracy of classification for MED-SAIL. RESULTS: The items included in MED-SAIL demonstrated internal consistency (5 items; α = 0.85). MED-SAIL was significantly correlated with the Independent Living Scales (r = 0.573, p ≤0.001) and instrumental activities of daily living (r = 0.440, p ≤0.01). The Mann-Whitney U test revealed significant differences between the no capacity and partial/full capacity classifications on MED-SAIL (U(48) = 60.5, Z = -0.38, p <0.0001). The area under the curve was 0.864 (95% confidence interval: 0.84-0.99). CONCLUSIONS: This study demonstrated the validity of MED-SAIL as a brief screening tool to identify older adults with impaired capacity for remaining safe and independent in their current living environment. MED-SAIL is useful tool for health and social service providers in the community for the purpose of referral for definitive capacity evaluation.

Six-month postintervention depression and disability outcomes of in-home telehealth problem-solving therapy for depressed, low-income homebound older adults.

BACKGROUND: Despite their high rates of depression, homebound older adults have limited access to evidence-based psychotherapy. The purpose of this paper was to report both depression and disability outcomes of telehealth problem-solving therapy (tele-PST via Skype video call) for low-income homebound older adults over 6 months postintervention. METHODS: A 3-arm randomized controlled trial compared the efficacy of tele-PST to in-person PST and telephone care calls with 158 homebound individuals who were aged 50+ and scored 15+ on the 24-item Hamilton Rating Scale for Depression (HAMD). Treatment effects on depression severity (HAMD score) and disability (score on the WHO Disability Assessment Schedule [WHODAS]) were analyzed using mixed-effects regression with random intercept models. Possible reciprocal relationships between depression and disability were examined with a parallel-process latent growth curve model. RESULTS: Both tele-PST and in-person PST were efficacious treatments for low-income homebound older adults; however the effects of tele-PST on both depression and disability outcomes were sustained significantly longer than those of in-person PST. Effect sizes (dGMA-raw ) for HAMD score changes at 36 weeks were 0.68 for tele-PST and 0.20 for in-person PST. Effect sizes for WHODAS score changes at 36 weeks were 0.47 for tele-PST and 0.25 for in-person PST. The results also supported reciprocal and indirect effects between depression and disability outcomes. CONCLUSIONS: The efficacy and potential low cost of tele-delivered psychotherapy show its potential for easy replication and sustainability to reach a large number of underserved older adults and improve their access to mental health services.

Lay providers can deliver effective cognitive behavior therapy for older adults with generalized anxiety disorder: a randomized trial.

BACKGROUND: The Institute of Medicine recommends developing a broader workforce of mental health providers, including nontraditional providers, to expand services for older adults. Cognitive behavior therapy (CBT) is effective for late-life generalized anxiety disorder (GAD), but no study has examined outcomes with delivery by lay providers working under the supervision of licensed providers. The current study examined the effects of CBT delivered by lay, bachelor-level providers (BLP) relative to Ph.D.-level expert providers (PLP), and usual care (UC) in older adults with GAD. METHODS: Participants were 223 older adults (mean age, 66.9 years) with GAD recruited from primary care clinics at two sites and assigned randomly to BLP (n = 76), PLP (n = 74), or UC (n = 73). Assessments occurred at baseline and 6 months. CBT in BLP and PLP included core and elective modules (3 months: skills training; 3 months: skills review) delivered in person and by telephone, according to patient choice. RESULTS: CBT in both BLP and PLP groups significantly improved GAD severity (GAD Severity Scale), anxiety (Spielberger State-Trait Anxiety Inventory; Structured Interview Guide for the Hamilton Anxiety Scale), depression (Patient Health Questionnaire), insomnia (Insomnia Severity Index), and mental health quality of life (Short-Form-12), relative to UC. Response rates defined by 20% reduction from pre- to posttreatment in at least three of four primary outcomes were higher for study completers in BLP and PLP relative to UC (BLP: 38.5%; PLP: 40.0%; UC: 19.1%). CONCLUSION: Lay providers, working under the supervision of licensed providers, can deliver effective CBT.

Treating late-life generalized anxiety disorder in primary care: an effectiveness pilot study.

To increase the sustainability of cognitive behavior therapy (CBT) in primary care for late-life anxiety, we incorporated nonexpert counselors, options for telephone meetings, and integration with primary care clinicians. This open trial examines the feasibility, satisfaction, and clinical outcomes of CBT delivered by experienced and nonexperienced counselors for older adults with generalized anxiety disorder (GAD). Clinical outcomes assessed worry (Penn State Worry Questionnaire), GAD (Generalized Anxiety Disorder Severity Scale), and anxiety (Beck Anxiety Inventory and Structured Interview Guide for Hamilton Anxiety Scale). After 3 months of treatment, Cohen's d effect sizes for worry and anxiety ranged from 0.48 to 0.78. Patients treated by experienced and nonexperienced counselors had similar reductions in worry and anxiety, although treatment outcomes were more improved on the Beck Anxiety Inventory for experienced therapists. Preliminary results suggest that adapted CBT can effectively reduce worry. The piloted modifications can provide acceptable and feasible evidence-based care.

Negative caregiving effects among caregivers of veterans with dementia.

OBJECTIVES: : This investigation was guided by the stress process model and had two objectives: first, to describe the extent of negative caregiving effects for family caregivers of veterans with dementia, and second, to identify salient predictors of negative caregiving effects. DESIGN: : Data were obtained from baseline, structured telephone interviews with family caregivers of veterans enrolled in "Partners in Dementia Care," a clinical trial testing a care coordination intervention. PARTICIPANTS: : The study included 486 family caregivers of veterans with dementia who received primary care from the Department of Veterans Affairs healthcare system and lived at home. MEASUREMENT: : Six negative caregiving effects were described as follows: unmet needs, four role and intrapsychic strains, and depression. Predictive factors included the following: cognitive impairment, behavior problems, personal care dependency, number of chronic conditions, and characteristics of the caregiving context. RESULTS: : Sizeable portions of caregivers experienced negative caregiving effects; most common were unmet needs, social isolation, and depression. Cognitive, behavioral, and functional symptoms of dementia and other coexisting chronic conditions explained significant variation in all negative caregiving effects. Caregiving context had little impact. Behavior problems were the most consistent predictor; personal care dependency and other chronic conditions were also important. CONCLUSIONS: : Family caregivers, the foundation of long-term care for veterans with dementia who live at home, experience a variety of negative caregiving effects. Negative effects are greater when veterans exhibit behavior problems, require extensive assistance with personal care, and have a greater number of coexisting chronic conditions. Negative caregiving effects are an important target for interventions that support family caregivers and promote continued care at home.

An educational program to assist clinicians in identifying elder investment fraud and financial exploitation.

Due to age-related factors and illnesses, older adults may become vulnerable to elder investment fraud and financial exploitation (EIFFE). The authors describe the development and preliminary evaluation of an educational program to raise awareness and assist clinicians in identifying older adults at risk. Participants (n = 127) gave high ratings for the program, which includes a presentation, clinician pocket guide, and patient education brochure. Thirty-five respondents returned a completed questionnaire at the 6-month follow-up, with 69% (n = 24) of those indicating use of the program materials in practice and also reporting having identified 25 patients they felt were vulnerable to EIFFE. These findings demonstrate the value of providing education and practical tools to enhance clinic-based screening of this underappreciated but prevalent problem.

Irritability and social isolation in dementia patients with and without depression.

UNLABELLED: This study examined the prevalence of irritability and social isolation in veterans with dementia, with and without depression. Participants were diagnosed with dementia and enrolled in a dementia care-coordination and support-service intervention. Participants were interviewed and underwent assessment with the 10-item Center for Epidemiologic Studies Depression scale, a Patient Strain Measure and the Short Blessed Test. In all, of 294 participants completing interviews, 77 (26.2%) were depressed and 107 (36.4%) endorsed irritability; mean social isolation score was 1.59 ± 1.96. Irritability was significantly more likely to be present in depressed versus nondepressed participants (P < .0001), but this relationship was moderated by dementia severity. The mean social isolation score was also significantly more elevated in depressed rather than nondepressed patients (2.82 ± 1.96 vs 1.15 ± 1.76, respectively). CONCLUSIONS: Depressed persons with dementia are significantly more likely to experience irritability and social isolation than those who are not depressed.

Treatment response for late-life generalized anxiety disorder: moving beyond symptom-based measures.

Response to treatment of late-life generalized anxiety disorder has been defined by a variety of methods, all based on statistically significant reductions in symptom severity. However, it is unknown whether these improvements in symptom severity are associated with meaningful differences in everyday functioning. The current study used four methods to define response to treatment for 115 primary-care patients 60 years and older, with a principal or coprincipal diagnosis of generalized anxiety disorder. The methods examined included percentage of improvement, reliable change index, and minimal clinically significant differences. Agreement among classification methods and their associations with general and mental health-related quality of life were assessed. Results indicated moderate agreement among symptom-based classification methods and significant associations with measures of quality of life.

The involvement of multiple caregivers in cognitive-behavior therapy for anxiety in persons with dementia.

OBJECTIVES: Peaceful Mind, a cognitive-behavioral therapy for treating anxiety in persons with dementia, is a promising new treatment currently under investigation. This article reports results of our examination of a modification of the treatment protocol in two cases that included multiple caregivers in treating two persons with dementia. METHOD: Two case presentations of the benefits and challenges of including multiple caregivers in treatment are discussed. Treatment outcome data for these cases were collected as part of a larger investigation of Peaceful Mind. RESULTS: The involvement of multiple collaterals resulted in several benefits, including increased family communication, as well as increased opportunities for the practice of new skills. These cases have also presented unique challenges requiring alterations in therapy structure and attention to issues of family conflict. CONCLUSIONS: Including multiple collaterals in cognitive-behavioral therapy for treating anxiety in persons with dementia is feasible and may be beneficial in maximizing treatment gains and increasing the family's investment in therapy.

Effect of Telehealth Treatment by Lay Counselors vs by Clinicians on Depressive Symptoms Among Older Adults Who Are Homebound: A Randomized Clinical Trial.

Importance: Older adults who are homebound and have low income have limited access to psychosocial treatments because of their homebound state and geriatric mental health workforce shortages. Objective: To evaluate clinical effectiveness of a brief, aging service-integrated, videoconferenced behavioral activation (tele-BA) treatment delivered by lay counselors compared with videoconferenced problem-solving therapy (tele-PST) delivered by licensed clinicians and attention control (AC; telephone support calls). Design, Setting, and Participants: This 3-group randomized clinical trial using a randomization prior to consent approach included individuals aged 50 years or older who were homebound and had 24-item Hamilton Depression Rating Scale (HAMD) scores of 15 or greater between February 15, 2016, and April 15, 2019. Tele-BA and tele-PST participants received 5 weekly treatment sessions. Assessments were performed at baseline and 12, 24, and 36 weeks after baseline. Intention-to-treat statistical analyses were performed from January 1, 2020, to February 15, 2020. Interventions: Tele-BA participants were taught 5 steps for reinforcing healthy behaviors to improve mood, physical functioning, and social engagement. Tele-PST participants were taught a 7-step approach for problem solving coping skills. Main Outcomes and Measures: The primary outcome was the 24-item HAMD scores. Response (ie, ≥50% reduction in HAMD) and remission (ie, HAMD <10) rates and effect sizes for clinically meaningful differences were examined. Secondary outcomes were disability, social engagement and activity frequency, and satisfaction with participation in social roles. Results: A total of 277 participants were enrolled, including 193 (69.7%) women, 83 (30.0%) who were Black, 81 (29.2%) who were Hispanic, and 255 (92.1%) with income of $35 000 or less. The mean (SD) age was 67.5 (8.9) years. Among these, 90 participants were randomized to tele-BA, 93 participants were randomized to tele-PST, and 94 participants were randomized to the AC. Compared with participants in the AC group, participants in the tele-BA and tele-PST groups had significantly higher response and remission rates and medium to large effect sizes (tele-BA: raw growth modeling analysis d = 0.62 [95% CI, 0.35 to 0.89]; P < .001; tele-PST: raw growth modeling analysis d = 1.00 [95% CI, 0.73 to 1.26]; P < .001) for HAMD scores. While tele-PST was significantly more effective than tele-BA for reducing HAMD scores (t258 = -2.79; P = .006), there was no difference between tele-BA and tele-PST on secondary outcomes. Conclusions and Relevance: In this randomized clinical trial, participants who received tele-BA by lay counselors achieved statistically and clinically meaningful changes in depressive symptoms. Given shortages of licensed mental health clinicians, tele- and lay counselor-delivered services may help improve access to evidence-based depression treatment for large numbers of underserved older adults. Trial Registration: ClinicalTrials.gov Identifier: NCT02600754.

Validation of the MEDSAIL Tool to Screen for Capacity for Safe and Independent Living Among Nursing Home Residents.

OBJECTIVES: Capacity for safe and independent living (SAIL) refers to an individual's ability to solve problems associated with everyday life and perform activities necessary for living independently. Little guidance exists on the assessment of capacity for SAIL among nursing home residents. As a result, capacity for SAIL is not fully considered in the development of discharge plans to ensure safety and independence in the community. We reasoned that this problem could be addressed with the Making and Executing Decisions for Safe and Independent Living (MEDSAIL) tool, developed to screen for capacity for SAIL among community-dwelling older adults. In this report, we describe findings on the validity of the MEDSAIL when used with nursing home residents. DESIGN: Prospective cross-sectional pilot study. SETTING AND PARTICIPANTS: Twenty-four residents of a Veterans Health Affairs Community Living Center (CLC; nursing home); exclusion criteria were cognitive impairment too severe to complete the protocol, diagnosis of serious mental illness or developmental disability, inability to hear, or inability to communicate verbally. METHODS: Participants completed 2 assessments: the MEDSAIL interview administered by a research assistant and the criterion standard capacity interview administered by a geriatric psychiatrist. We examined internal consistency, divergent validity, and criterion-based validity. RESULTS: Five of 7 MEDSAIL scenarios approximated acceptable levels of internal consistency (α >0.70). MEDSAIL scores were highly positively correlated with criterion standard capacity determination (0.88, P = .001), and the Wilcoxon rank-sum test statistic for the 2 assessments was also statistically significant (P = .001). CONCLUSIONS AND IMPLICATIONS: MEDSAIL has promise as a user-friendly brief screening tool for use by nursing home staff to understand resident capacity for SAIL. This information can be used in the development of discharge plans to keep the resident safe and independent in the community. In addition, tailoring the MEDSAIL scenarios specifically to the nursing home setting may further enhance the tool's validity and utility in this new application.

Cognitive behavior therapy for generalized anxiety disorder among older adults in primary care: a randomized clinical trial.

CONTEXT: Cognitive behavior therapy (CBT) can be effective for late-life generalized anxiety disorder (GAD), but only pilot studies have been conducted in primary care, where older adults most often seek treatment. OBJECTIVE: To examine effects of CBT relative to enhanced usual care (EUC) in older adults with GAD in primary care. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial recruiting 134 older adults (mean age, 66.9 years) from March 2004 to August 2006 in 2 primary care settings. Treatment was provided for 3 months; assessments were conducted at baseline, posttreatment (3 months), and over 12 months of follow-up, with assessments at 6, 9, 12, and 15 months. INTERVENTION: Cognitive behavior therapy (n = 70) conducted in the primary care clinics. Treatment included education and awareness, motivational interviewing, relaxation training, cognitive therapy, exposure, problem-solving skills training, and behavioral sleep management. Patients assigned to receive EUC (n = 64) received biweekly telephone calls to ensure patient safety and provide minimal support. MAIN OUTCOME MEASURES: Primary outcomes included worry severity (Penn State Worry Questionnaire) and GAD severity (GAD Severity Scale). Secondary outcomes included anxiety ratings (Hamilton Anxiety Rating Scale, Beck Anxiety Inventory), coexistent depressive symptoms (Beck Depression Inventory II), and physical/mental health quality of life (12-Item Short Form Health Survey). RESULTS: Cognitive behavior therapy compared with EUC significantly improved worry severity (45.6 [95% confidence interval {CI}, 43.4-47.8] vs 54.4 [95% CI, 51.4-57.3], respectively; P < .001), depressive symptoms (10.2 [95% CI, 8.5-11.9] vs 12.8 [95% CI, 10.5-15.1], P = .02), and general mental health (49.6 [95% CI, 47.4-51.8] vs 45.3 [95% CI, 42.6-47.9], P = .008). There was no difference in GAD severity in patients receiving CBT vs those receiving EUC (8.6 [95% CI, 7.7-9.5] vs 9.9 [95% CI, 8.7-11.1], P = .19). In intention-to-treat analyses, response rates defined according to worry severity were higher following CBT compared with EUC at 3 months (40.0% [28/70] vs 21.9% [14/64], P = .02). CONCLUSIONS: Compared with EUC, CBT resulted in greater improvement in worry severity, depressive symptoms, and general mental health for older patients with GAD in primary care. However, a measure of GAD severity did not indicate greater improvement with CBT. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00308724.

Does care consultation affect use of VHA versus non-VHA care?

OBJECTIVES: The Partners in Dementia Care (PDC) intervention has shown improved psychosocial outcomes while reducing overall inpatient and emergency department (ED) utilization among veterans with cognitive impairment and behavioral symptoms. However, veterans who use the Veterans Health Administration (VHA) also seek care from non-VHA sources, potentially reducing the effectiveness of care coordination. We evaluated whether PDC affected VHA and non-VHA inpatient and ED use by veterans with dementia. STUDY DESIGN: PDC is a telephone-based care coordination and support service program implemented in 2 VHA intervention sites that were compared with 3 VHA control sites. Veterans with a dementia diagnosis and their caregivers participated. METHODS: Data came from administrative records and structured interviews with caregivers. We modeled the likelihood of site of care across 3 periods: preintervention (baseline), baseline to 6 months, and 6 months to 12 months. RESULTS: Compared with veterans at control sites, veterans at intervention sites who lived closer to VHA medical centers showed an increase over time (P ≤.01) in the likelihood of seeking VHA inpatient care as opposed to non-VHA care, whereas the likelihood of seeking non-VHA relative to VHA inpatient care increased for veterans living further away. ED visits did not show a comparable intervention effect. CONCLUSIONS: PDC intervention affected the choice of VHA versus non-VHA inpatient care, with its impact differing by distance from VHA medical centers. Site of ED care was not affected. Accountable care organizations share some of the VHA's vulnerabilities to out-of-system use; thus, the implications of our findings extend beyond the VHA system.

Utility of telephone assessments in an older adult population.

Telephone assessments are commonly used in mental health research and may be especially beneficial in older populations. The current study assessed the psychometric properties of the Penn State Worry Questionnaire (T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990) and the Beck Depression Inventory--II (A. T. Beck, R. A. Steer, & G. K. Brown, 1996), when administered over the telephone in an older adult population. Results indicate no differences in mean symptom level or internal consistency across two modes of administration. Correlations between the in-person and telephone-administered measures and diagnostic categories suggest adequate validity of the telephone-administered measures. With this demonstrated evidence, the telephone assessment method can be applied in a variety of research and clinical settings.