The Alabama REACH Demonstration Project (ARDP)A case example using the RE-AIM model Lou Burgio, Ph.D.

University of AlabamaCenter for Mental Health and Aging

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RERE--AIM TO HELP PLAN, EVALUATE, AIM TO HELP PLAN, EVALUATE, AND REPORT STUDIESAND REPORT STUDIES

RR IncreaseIncrease RReacheach

EE IncreaseIncrease EEffectivenessffectiveness

AA IncreaseIncrease AAdoptiondoption

I I IncreaseIncrease IImplementationmplementation

MM IncreaseIncrease MMaintenanceaintenance

Glasgow, et al. Ann Behav Med 2004;27(1):3-12

RE-AIM

Background

• 2004, with AoA funds, ADSS started partnership with UA to modify REACH clinical trial protocol so that it is feasible in the community.

• Supervision of resulting treatment program would be by four Area Agencies on Aging (AAA), and case managers from AAAs would serve as interventionists.

Role of University

• Work with AAAs to design workable program: modify treatment manuals and procedures

• Train case workers to use intervention in clients’ homes.

• Be available by phone for case consultation

• Maintain data management and conduct data analysis

Resulting Intervention

1. Risk Assessment2. Education about AD, Caregiving,

and Stress3. Caregiver Health(Health Passport)

and Home Safety (use of checklist)4. Behavior Management5. Signal Breath (simple relaxation)

Procedural Modifications

• Four, hour-long home visits over a 3-4 month period

• Three phone calls interspersed among home visits

RE-AIM Application to ARDP• What we did

• Factors to consider (suggested by RE-AIM)

RE-AIM

1010

RERE--AIM TO HELP PLAN, EVALUATE, AIM TO HELP PLAN, EVALUATE, AND REPORT STUDIESAND REPORT STUDIES

RR IncreaseIncrease RReacheach

EE IncreaseIncrease EEffectivenessffectiveness

AA IncreaseIncrease AAdoptiondoption

I I IncreaseIncrease IImplementationmplementation

MM IncreaseIncrease MMaintenanceaintenance

Glasgow, et al. Ann Behav Med 2004;27(1):3-12

RE-AIM ELEMENTS: REACH• Definition: The number, percent of

target audience, and representativeness of those who participate.

• What we did:– Four AAAs chosen by ADSS: two rural

and two urban– Of the 272 dyads present at first home

visit, 97% attended all four home visits

RE-AIM ELEMENTS: REACHFactors to consider• Need data on total number of

caregivers contacted for participation

• Characteristics of caregivers who did and did not participate

RE-AIM ELEMENTS: EFFECTIVENESS• Definition: Change in temporally

appropriate outcomes, and impact on quality of life and any adverse outcomes.

Treatment Effects on CG Emotional Well-Being

N Mean(SD)1

Mean(SD)2

t-value p-value Effect size d

Zarit Burden Scale(higher = more burden)

228 2.40(.74)

2.23(.65)

3.71 .0001 .25

Social Support past month(higher = better support)

224 2.87(.98)

3.16(.82)

-4.52 .0001 -.30

Depression in the last week(higher = more depressed)

227 2.10(.86)

1.91(.82)

3.35 .001 .22

Positive Aspect of Caregiving(higher = more PAC)

229 3.94(1.07)

4.17(1.01)

-3.51 .001 -.23

ADL Stress(higher = more stress)

230 1.97(.78)

1.87(.73)

1.84 .07 .12

CG Bothered by CR mem/beh problems in the last

week(higher = more bother)

200 2.29(1.43)

2.08(1.29)

1.84 .07 .13

Felt like screaming, yelling, hit/slap CR

(higher = more stress)

228 1.39(.46)

1.26(.38)

5.01 .0001 .33

Overall Improvements in Behavioral Problems of the CR

Baseline N=267 Yes: 50 (19%) No: 217 (81%)

Time Point 2(T2)

N=224 Yes: 85 (38%) No: 139 (62%)

Change over time

N=221 (cases

excluded test-wise)

No at Baseline & T2: 120 (54%)No at baseline, Yes at T2: 61

(28%)

Yes at Baseline & T2:

24 (11%)Yes at Baseline,

No at T2: 16 (7%)A McNemar Chi‐square test was used to evaluate the response to a question about overall improvement in behavioral problems in the CR over the past 4 months, at pre and post‐intervention. A statistically significant change over time was found (N = 221, X2=25.14, p<.001).

Improvement in Behavior Problems • Post-treatment, caregivers

reported significant improvement in behavior problems (p<.001)

Treatment Effects on Caregiver Health

N Mean(SD)1

Mean(SD)2

t-value p-value Effect size d

Perceived change in Health(higher = worse health)

227 3.19(.64)

2.95(.65)

4.82 .0001 .32

Sleep(higher = worse sleep)

225 2.23(.70)

2.11(.69)

2.55 .01 .17

Client Satisfaction Survey Part I

(strongly disagree) 1 – 4 (strongly agree)

N Mean (SD)

Valid Percent

Types 236

3.47 (.51) 99% responded 3-4

Quality 236

3.52 (.43) 98% responded 3-4

Information 236

3.53 (.42) 98% responded 3-4

Client Satisfaction Survey Part II

(very helpful) 1 – 3 (not helpful)

N Mean (SD)

Valid Percent

Info about AD 236

1.22 (.42) 78% responded 1;

22% responded 2

Info CG and Stress 236

1.28 (.47) 73% responded 1;

26% responded 2

Home safety 236

1.43 (.57) 60% responded 1;

36% responded 2

Health passport 234

1.46 (.55) 57% responded 1;

40% responded 2

Behavioral Prescriptions 233

1.49 (.59) 54% responded 1;

43% responded 2

Signal Breath 229

1.51 (.59) 53% responded 1;

41% responded 2

Client Satisfaction Survey Part III

1 (too many); 2 (too few); 3 (about right)

N Mean (SD)

Valid Percent

# home visits 236

2.78 (.46) 81% responded 3;

17% responded 2

# phone calls 236

2.83 (.46) 87% responded 3;9% responded

2

RE-AIM ELEMENTS: EFFECTIVENESSFactors to consider• Are any caregiver or case manager

factors associated with outcome?• Is there any negative impact of

intervention?• Can program be shortened?

Component analysis? Input by case managers and caregivers?

RE-AIM ELEMENTS: ADOPTION• Definition: Number, percent and

representativeness of settings and clinicians who participate.

• What we did:– Near the end of the project, every

case manager in Alabama was taught REACH intervention in two-day workshop (all AAAs involved)

RE-AIM ELEMENTS: ADOPTIONFactors to consider• How many AAAs were using REACH

intervention after the state-wide workshop?

• How many case managers within AAAs actually used REACH interventions after state-wide workshop?

• What were the characteristics of those who did and those who did not?

RE-AIM ELEMENTS: IMPLEMENTATIONDefinition: Extent to which a program or policy

is delivered consistently; what are the time investment and costs of the program.

• What we did:– A form was used by case managers to track

the number of home visits/phone calls, but also to record therapeutic activities during the visits

– Case managers reported using the treatment components from 88.6% (caregiver passport) to 98.5% (safety checklist) of the time

RE-AIM ELEMENTS: IMPLEMENTATIONFactors to consider• The program would benefit from

assessment of implementation costs to inform future allocations

RE-AIM ELEMENTS: MAINTENANCEDefinition: Individual/member target: Long-term effects

and attrition. Setting/clinician: Extent of discontinuation, modification, or sustainability of program.

• What we did:– Integrated REACH into Alabama CARES– CARES is long-standing program that offers

menu of services; REACH is now one of the services available

– All CARES team members attended two-day workshop to learn about REACH intervention

RE-AIM ELEMENTS: MAINTENANCEFactors to consider• Need longer assessment of

individual client maintenance• Need assessment of length of time

agencies kept REACH “active” within CARES

• Need application to other senior services, e.g. Senior Day Services