D-CARE: The Dementia Care Study: Design of a Pragmatic Trial of the Effectiveness and Cost Effectiveness of Health System-Based Versus Community-Based Dementia Care Versus Usual Dementia Care.

BACKGROUND/OBJECTIVES: Although several approaches have been developed to provide comprehensive care for persons living with dementia (PWD) and their family or friend caregivers, the relative effectiveness and cost effectiveness of community-based dementia care (CBDC) versus health system-based dementia care (CBDC) and the effectiveness of both approaches compared with usual care (UC) are unknown. DESIGN: Pragmatic randomized three-arm superiority trial. The unit of randomization is the PWD/caregiver dyad. SETTING: Four clinical trial sites (CTSs) based in academic and clinical health systems. PARTICIPANTS: A total of 2,150 English- or Spanish-speaking PWD who are not receiving hospice or residing in a nursing home and their caregivers. INTERVENTIONS: Eighteen months of (1) HSDC provided by a nurse practitioner or physician's assistant dementia care specialist who works within the health system, or (2) CBDC provided by a social worker or nurse care consultant who works at a community-based organization, or (3) UC with as needed referral to the Alzheimer's Association Helpline. MEASUREMENTS: Primary outcomes: PWD behavioral symptoms and caregiver distress as measured by the Neuropsychiatric Inventory Questionnaire (NPI-Q) Severity and Modified Caregiver Strain Index scales. SECONDARY OUTCOMES: NPI-Q Distress, caregiver unmet needs and confidence, and caregiver depressive symptoms. Tertiary outcomes: PWD long-term nursing home placement rates, caregiver-reported PWD functional status, cognition, goal attainment, "time spent at home," Dementia Burden Scale-Caregiver, a composite measure of clinical benefit, Quality of Life of persons with dementia, Positive Aspects of Caregiving, and cost effectiveness using intervention costs and Medicare claims. RESULTS: The results will be reported in the spring of 2024. CONCLUSION: D-CARE will address whether emphasis on clinical support and tighter integration with other medical services has greater benefit than emphasis on social support that is tied more closely to community resources. It will also assess the effectiveness of both interventions compared with UC and will evaluate the cost effectiveness of each intervention.

Socioecological factors and positive aspects of caregiving: findings from the REACH II intervention.

OBJECTIVE: Taking a socioecological perspective, this study assessed the relationship of intrapersonal, interpersonal, and organizational factors to positive aspects of caregiving (PAC) for 642 dementia caregivers by racial/ethnic group from the baseline data of the multisite Resources for Enhancing Alzheimer's Caregiver Health II (REACH II) intervention. METHODS: Nine intrapersonal indicators, 4 interpersonal indicators, and 12 organizational indicators were used. Blocked-multiple regression analyses by three racial/ethnic groups were computed to examine significant factors related to PAC among caregivers after controlling for memory and behavioral problems. RESULTS: Data showed a significant difference in PAC and significantly different indicators of PAC by racial/ethnic group. Hispanic caregivers reported the highest level of PAC while White participants showed the lowest scores on the measure of PAC. Education, marital status, and using formal transportation services were significant predictors for PAC among Hispanic caregivers; age, education, caregiving duration, and received social support were significant for PAC among African American caregivers; and sex, education, being a spousal caregiver, satisfaction with social support, using help from homemaker and visiting nurse services, and participating in support groups were significant among White caregivers. CONCLUSION: Findings indicate that PAC varies significantly across the three studied racial/ethnic groups of family caregivers and that intrapersonal, interpersonal, and organizational factors relate uniquely to PAC. Additional investigations of PAC could serve an important role in the development of family caregiving supports and services.

Emerging frontiers in healthcare research and delivery.: the 16th Annual HMO Research Network Conference, March 21-24, 2010, Austin, Texas.

The Health Maintenance Organization Research Network (HMORN), a consortium of 16 healthcare delivery systems with integrated research centers, held their 16(th) annual conference in Austin, Texas from March 21-24, 2010. The conference was hosted by Scott & White Healthcare. Its theme "Emerging Frontiers in Healthcare Research and Delivery" reflected the objective of the conference which was to build synergy among scientists and clinicians to influence the health of the nation; to demonstrate the network's commitment to reach beyond traditional collaborators; discuss tools and technologies; and to expand opportunities for public-private partnerships in cutting-edge healthcare research and delivery. More than 320 researchers and healthcare professionals, representing each of the member HMOs, participated in this conference. Representatives from the AHRQ, CDC, NCI and NIH met with researchers to advance the quality and breadth of public domain research in HMOs. The objective of this article is to provide information about the HMORN and its 16(th) annual conference.

Making the Most of Your Healthcare intervention for older adults with multiple chronic illnesses.

OBJECTIVE: This study tested the efficacy of a patient engagement intervention for older adults with multiple chronic illnesses. METHODS: Seventy-nine participants were randomly assigned to receive the intervention (Intervention Group), contacts on a different topic (Safety Group), or Usual Care. The Intervention and Safety Groups attended a 2-h workshop and participated in phone calls; one before and one after a naturally-occurring medical encounter. The Intervention Group discussed patient engagement concepts from publicly distributed content. The Safety Group discussed general safety (e.g., fire safety, identity theft). Self-report measures were gathered by telephone interview at Baseline and 6-months following Baseline. RESULTS: We did not find expected improvements in patient activation and health-related quality of life. However, the Intervention Group was the only group to show a statistically significant improvement in self-efficacy for self-management. CONCLUSION: The intervention shows promise for improving quality of life and/or health, but requires refinement to reach persons not already engaged in their healthcare and to strengthen its effects. PRACTICE IMPLICATIONS: Patient-directed skills training interventions may be a successful way to support clinicians' and others' efforts to encourage older patients to be actively involved in their care.

Predictors of discharges to a nursing home in a hospital-based cohort.

BACKGROUND: Nursing home (NH) placement among older adults is influenced by numerous factors and is associated with multiple problematic outcomes. Interventions to prevent or delay NH placement have mainly been researched in the community. However, prediction of these factors during hospitalization could provide an ideal opportunity to shape targeted interventions among high-risk patients. The purposes of this investigation were to compare characteristics of patients discharged to the community and those discharged to the NH, and to identify predictors of NH placement. METHODS: A retrospective hospital-based cohort design was used to identify predictors of NH placement. Information about the study population was obtained from Scott and White (S&W) Healthcare's Electronic Medical Records and billing records. Study participants included S&W persons discharged to the community (n=5025) or to a nursing home (n=981). Descriptive characteristics were compared between community discharges and NH discharges using chi(2) statistic for categorical data and t test for continuous variables. Multiple logistic regression models were performed to identify the most salient predictors of NH placement. RESULTS: Traditional risk factors, such as having less caregiving support, using more hospital services, being more severely ill, and not understanding their illness, characterized persons discharged to the NH compared with community-discharged persons. Significant predictors of being discharged to the NH included longer hospitalizations, not understanding one's illness, being female, living alone, not having a caregiver, needing assistance with dressing, and having a fall risk. CONCLUSION: In conclusion, these results could help develop hospital-based interventions to postpone or prevent NH placement among high-risk patients.

Enhancing the quality of life of dementia caregivers from different ethnic or racial groups: a randomized, controlled trial.

BACKGROUND: Caring for a family member with dementia is extremely stressful, contributes to psychiatric and physical illness among caregivers, and increases the risk for caregiver death. Finding better ways to support family caregivers is a major public health challenge. OBJECTIVE: To test the effects of a structured multicomponent intervention on quality of life and clinical depression in caregivers and on rates of institutional placement of care recipients in 3 diverse racial or ethnic groups. DESIGN: Randomized, controlled trial. SETTING: In-home caregivers in 5 U.S. cities. PARTICIPANTS: 212 Hispanic or Latino, 219 white or Caucasian, and 211 black or African-American caregivers and their care recipients with Alzheimer disease or related disorders. INTERVENTION: Caregivers within each racial or ethnic group were randomly assigned to an intervention or to a control group. The intervention addressed caregiver depression, burden, self-care, and social support and care recipient problem behaviors through 12 in-home and telephone sessions over 6 months. Caregivers in the control group received 2 brief "check-in" telephone calls during the 6-month intervention. MEASUREMENTS: The primary outcome was a quality-of-life indicator comprising measures of 6-month caregiver depression, burden, self-care, and social support and care recipient problem behaviors. Secondary outcomes were caregiver clinical depression and institutional placement of the care recipient at 6 months. RESULTS: Hispanic or Latino and white or Caucasian caregivers in the intervention group experienced significantly greater improvement in quality of life than those in the control group (P < 0.001 and P = 0.037, respectively). Black or African-American spouse caregivers also improved significantly more (P = 0.003). Prevalence of clinical depression was lower among caregivers in the intervention group (12.6% vs. 22.7%; P = 0.001). There were no statistically significant differences in institutionalization at 6 months. LIMITATIONS: The study used only a single 6-month follow-up assessment, combined heterogeneous cultures and ethnicities into a single group, and excluded some ethnic groups. CONCLUSIONS: A structured multicomponent intervention adapted to individual risk profiles can increase the quality of life of ethnically diverse dementia caregivers. ClinicalTrials.gov identifier: NCT00177489.

Team functioning and patient outcomes in stroke rehabilitation.

OBJECTIVE: To evaluate the relationship between rehabilitation team functioning and stroke patient outcomes. DESIGN: Prospective observational study. SETTING: Veterans Administration (VA) inpatient and subacute rehabilitation units. PARTICIPANTS: Forty-six VA rehabilitation teams, including 530 rehabilitation team members from 6 disciplines (medicine, nursing, social work, physical therapy, occupational therapy, speech language pathology) and 1688 stroke patients treated by the teams. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Ten scales assessing team member perceptions of team functioning (communication, perceived effectiveness, physician involvement, physician support, teamness, utility of quality information, innovation, interprofessional relationships, order and organization, task orientation) and 3 primary patient outcome variables-functional improvement, discharge home, and length of rehabilitation stay (LOS). RESULTS: Three of the 10 measures of team functioning were significantly associated with patient functional improvement ( P <.05): task orientation, order and organization, and utility of quality information. One measure of team functioning-effectiveness-was significantly associated with LOS ( P <.05). None of the team variables predicted discharge destination. Aspects of team functioning that were important to outcomes differed depending on the outcome of interests. Efforts directed toward improving team activities and relationships, including collaborative planning and problem solving and the use of feedback information, may enhance rehabilitation treatment effectiveness. CONCLUSIONS: Characteristics of team functioning predict selected rehabilitation outcomes.