Barbara G. Vickrey, MD, MPH Associate Professor, UCLA Dept of Neurology
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Transcript of Barbara G. Vickrey, MD, MPH Associate Professor, UCLA Dept of Neurology
Getting Evidence-Based Psychosocial Treatments into
Practice Roundtable: Evidence & Challenges from a Dementia Care Management Quality Improvement Trial
Barbara G. Vickrey, MD, MPHAssociate Professor, UCLA Dept of Neurology
Principal Investigator, ACCESS
June 6, 2004
Burden of Dementia• Most common cause is Alzheimer’s disease
• Elderly in US will double between 1990 and 2030; prevalence of dementia rises with age: 1% of those > age 60, 40% of those > age 85
• Enormous financial costs: ~$100 billion total costs in 1994 (largely nursing home costs)
• Enormous ‘human costs’ (health impacts) on affected persons and family…
Health Impacts of Dementia• Disruptive behaviors are common:
Agitation ~50% Aggression ~20% Delusions ~33% Wandering ~25%
• Patient depression is common/underrecognized• Memory loss complicates management of comorbid
medical conditions • Safety issues related to driving risks, wandering,
vulnerability to abuse• Family (informal) caregivers have high rates of
depression/stress/burden
Ultimate Goals of Optimal Dementia Care
Health; Satisfaction with Care:• patient behavior problems & depression • caregiver burden, depression, stress• satisfaction with care/care coordination
Cost/Utilization:• or delay nursing home use• avoidable hospitalizations/ER use• indirect costs due to family caregiver
loss of or reduced employment
Evidence-Based Dementia Care Process/Outcomes Links
•Cholinesterase inhibitors delay cognitive decline in mild to moderate AD
•Non-pharmacologic approaches can reduce behavior problems
•Alzheimer’s Assoc. Safe Return Program can reduce wandering risk and delays in identification of wanderers
•Caregiver support, education, collaborative problem-solving and/or respite programs can delay nursing home placement
Example: Impact of Caregiver Support & Education
(Mohide et al JAGS 1990)Design: RCTSample: 86 dementia patient/caregiver dyads Controls: Usual care with VNA visitsExperimental: Education; encourage support grp
copy of 36 Hour Day; 4 hrs respite care/wk
6-month outcomes, control vs. experimental• no difference in % placed in long term care: 55 vs. 50%• time to placement: 10.4 vs. 17.2 weeks (p<0.05)• caregiver quality of life, depression, & anxiety not
different
Traditional Sources of Selected Evidence-Based Care Processes
Process Medical system
Community agencies
Cholinesterase inhibitors
X
Behavior problems x X
Safe Return Program X
Caregiver support, education, respite
x X
Evidence-Practice Gapsin Dementia Care
0102030405060708090
100
% ever receiving
some or all they needed
of service
Alz Assocservice(s)
CaregiverCtr service
Supportgroup
Respitecare
health plan sample with dementia, mean duration 2.5 yrs
Barriers to Adherence to Dementia Care Guidelines
Time constraints of physicians/lack of reimbursement for other level providers
Lack of care coordination especially between traditional medical system and community agencies
Lack of proactive follow-up to reduce risk of escalation of problems
Patients (caregivers) inadequately educated/activated to manage their illness
Kaiser Permanente San DiegoScripps Clinic
University of California San Diego HealthcareMeals-on-Wheels Greater San Diego
Alzheimer’s Association San Diego ChapterSouthern Caregiver Resource CenterUniversity of California, Los Angeles
Funding Agencies:California HealthCare Foundation, California Department of
Aging, California Department of Health Services
Project Partners:
ACCESS Study GoalsDesign evidence-based care management intervention for improving dementia care quality
Implement the intervention in diverse health care organizations, partnering with key community agencies that focus on dementia/caregivers
Test the intervention’s impacts on quality of dementia care, as measured by adherence to a set of dementia care guidelines
Existing Dementia Care Structure
Patient Patient Caregiver(s)Caregiver(s)
Health Care SystemsHealth Care Systems
•Primary Care PhysiciansPrimary Care Physicians• Other Care ProvidersOther Care Providers
Community AgenciesCommunity Agencies
•Usual Care ProvidersUsual Care Providers
Structure and Relationships in ACCESS QI Model
Patient Patient Caregiver(s)Caregiver(s)
Health Care OrgsHealth Care Orgs• Dementia Care ManagersDementia Care Managers
• Primary Care PhysiciansPrimary Care Physicians• Other Care ProvidersOther Care Providers
Community AgenciesCommunity Agencies• Dementia Care ManagersDementia Care Managers
• Usual Care ProvidersUsual Care Providers
IT (CaseTrakker)
Multi-component ACCESS Intervention
Dementia care managers • at each health care organization and each
community agency• home visits: structured assessments
triggering care actions• proactive, regular follow-up
Formal procedures for referral to and communication with community agencies and with primary care MDs
ACCESS Intervention (cont’d) Identification of local champions Collaborative development of care plan
with caregivers/caregiver education/ caregiver activation
Internet-based case management software:• Automated triggers generating problem lists• Templates for care planning/PCP
communication• Tracking system to follow multiple cases• Pen-tablets for home assessments
Provider education
ACCESS Study Design Pre-post, experimental design with 18-month
follow-up Group-level randomized trial, with clinic as
randomization unit Collaboration of 3 healthcare orgs and 3
community agencies focusing on persons with dementia or their caregivers
Medicare pts >65 yrs, with dementia 408 pairs of patients & caregivers
238 – intervention; 170 - usual care
Key Findings to Date
ACCESS intervention group had significantly higher adherence to 24 of 30 dementia care guidelines compared to the usual care group (p<0.05) at 12-18 month follow-up, such as:Appropriate management of behavior
problemsReceipt of respite servicesEnrollment in Safe Return Program Development of a care planCholinesterase inhibitor use
QI Implementation Activities• Regular meetings of Steering Cmte of leadership
of the healthcare orgs, community agencies, and a consumer (caregiver), rotated across sites:– Selected which dementia care guidelines to target,
through formal consensus methods– Shared information to inventory services and
assessment tools and to decide on each org’s roles in the ACCESS model
– Subcommittees helped design assessment, care plan, and clinical management procedures
– Selected a project logo– Evaluated case management software options– Participated in annual site visits from funder
QI Implementation Activities (cont’d)
• Letters of support from senior leadership at all organizations
• Monthly meetings of dementia case managers from six organizations:– Resolve care coordination issues – Identify and address areas of unmet need,
I.e., invited speakers on key topics, shared print or electronic resources, etc.
• Advisory Board of consumer reps, researchers, state agency rep
Challenges Encountered in Implementation of the Research
• Complexity/burden of IRB approvals and recruitment procedures that protect privacy
• Proactive/preventive model was a paradigm shift (from reactive/crisis management) for care managers, their supervisors, and caregivers
• Creating solutions to coordination issues represented a cultural change for participating organizations (example: Safe Return Program) & required research team support
Challenges Encountered in Implementation (cont’d)
• While no major health care org changes occurred during the project, some changes in staffing and in health plan inclusion required flexibility to modify recruitment/enrollment protocols
• Differences in IT systems across organizations made implementing a common web-based software complex
• Human resource policies varied in restrictiveness across orgs, introducing delays in case manager hiring
Challenges to Sustainability• Evaluation outcome data - including
cost-effectiveness - not available at the time of decisions about sustainability within healthcare organizations (for whom most program costs would be borne)
• Insufficient attention during the project by project team/ Steering Cmte to building awareness/ promoting ACCESS at higher levels within healthcare organizations
Challenges to Replication• Most expensive ongoing component of
program is care managers, but currently no reimbursement mechanisms exist
• Full evaluation data not yet available, including impacts on health outcomes and analyses of relative impact of intervention components
• ACCESS model is already designed and tested, but multi-component intervention is still complex and requires adaptation, care manager training, and IT support
COMMUNITY AND RESEARCH COLLABORATORS
• UCLA Scripps Clinic– Karen Connor, RN, MBA Robert DeMonte MD– Susan Ettner, PhD Micheline Rochel, MSW– Joshua Chodosh, MD, MPH Vickie Dandridge– Martin Lee, PhD– Marjorie Pearson, PhD Alzheimer’s Association– Xin-ping Cui, PhD Tom Pamilla– Brian Mittman, PhD Lucia Eto
• Kaiser Permanente Southern Caregiver Resource Ctr– Pam Reger Lorie Van Tilburg, MSW– Terry Hoppe Edward Delaloza, MSW– Lisa Heikoff, MD – Sonda Kaldor, MSW Meals-on-Wheels San Diego– Sheila Hale, LCSW Roger Bailey, PhD Charles Fleischman
• UCSD Healthcare – Ted Ganiats, MD Consumer Representatives– Carol Taylor, RN, MSN Margo Fox Picou Tom Gillette, PhD