Implementation of the Program to Encourage Active and Rewarding Lives for Seniors (PEARLS)

Background: Depression is often undertreated in older adults. PEARLS is an evidence-based depression care management program for homebound elders. Although PEARLS exist in 10 states, full implementation has been limited. Aims: Working with multiple community partners, we studied several approaches for improving implementation and adapting PEARLS to address commonly identified barriers. We also developed and tested a PEARLS fidelity tool. Methods: Ten focus groups with 40 staff were formally analyzed to identify barriers to implementation. We used a single group design to test implementation approaches; data included process and outcome measures. We developed a 20-item fidelity instrument through key informant interviews with diverse stakeholders and validated the instrument using the known-groups method with 12 agencies. Results: Focus groups revealed strict eligibility criteria interfered with agency's mission to serve all clients. PEARLS modifications were piloted with interpreters for limited English-speaking clients and for clients with major depression. Depression response and remission rates were similar to the original model (80%). Using implementation coaching resulted in modest improvements in referral rates (9% to 15%) and enrollment rates (4% to 8%). Fidelity instrument testing showed longer established PEARLS programs had higher fidelity scores than newer programs, and PEARLS programs had higher fidelity scores compared to other types of depression programs (p<.05). Implications: PEARLS is an innovative program for treating late-life depression through community-based social service agencies. Ongoing technical assistance (TA) may be necessary; preliminary data suggest TA conference calls may help address common early implementation challenges and connect agencies to network around these issues.