Implementation in Health Care Implementation in Health Care and Social Service Systems: and Social Service Systems:

REACH VAREACH VA

Linda Olivia Nichols, PhD

Jennifer Martindale-Adams, EdD

VA Medical Center at Memphis, University of Tennessee Health Science Center

Resources for Enhancing Resources for Enhancing Alzheimer's Caregivers HealthAlzheimer's Caregivers Health

Multi-component 6 month, randomized clinical trial, 6/02 to 12/04

Funded by NIA and NINR, additional supportfrom VA

Five sites and Coordinating Center Recruited 642 caregiver dyads

African Americans/BlacksHispanics/LatinosCaucasians/Whites

R E

A C

H II

R E

A C

H II

InterventionInterventionInterventionTwelve individual sessions over six months in home and via telephone Five telephone support group sessions Intervention addressed:

EducationSafetyEmotional well beingSelf-careSocial supportPatient problem behaviors/caregiver skills

Twelve individual sessions over six months in home and via telephone Five telephone support group sessions Intervention addressed:

EducationSafetyEmotional well beingSelf-careSocial supportPatient problem behaviors/caregiver skills

R E

A C

H II

R E

A C

H II

Primary outcome - multivariate quality of life Depressive symptomsBurdenSelf-careSocial supportPatient problem behaviors/caregiver skills

Secondary outcomes Caregiver clinical depressionPatient institutional placement Vigilance

R E

A C

H II

R E

A C

H II

OutcomesOutcomesOutcomes

Improvement in quality of life for intervention, compared to control:

Hispanic/Latino caregivers (p < .001) White/Caucasian caregivers (p = .037)Black/African American spouse caregivers (p = .003)

Lower prevalence of clinical depression (p = .001) for intervention caregivers

R E

A C

H II

R E

A C

H II

FindingsFindingsFindings

Belle et al., Ann Int Med, 2006, 145,727Belle et al., Ann Int Med, 2006, 145,727--738738

Hours/DayTask On Duty

-2

-1.5

-1

-0.5

0

0.5

1

1.5

2

Change in Hours Over 6 Months

ControlControl

InterventionIntervention

F = 7.02F = 7.02

P = .008P = .008

.6.6--.5.5

R E

A C

H II

R E

A C

H II

Nichols et al., JAGS, 2008, 56:413Nichols et al., JAGS, 2008, 56:413--420420

-2

-1.5

-1

-0.5

0

0.5

1

1.5

2

Change in Hours Over 6 Months

InterventionIntervention

ControlControl.6.6

.2.2

F = 2.98F = 2.98

P = .085P = .085

One additional hour of non-caregiving time per day

at a

Cost of $4.96 per day per caregiver

R E

A C

H II

R E

A C

H II

Nichols et al., JAGS, 2008, 56:413Nichols et al., JAGS, 2008, 56:413--420420

REACH II implemented into a clinical setting

VHA SettingCaregiver Assistance pilot programHome Based Primary CarePsychologist, Social Worker, or NurseAdded to normal dutiesR

E A

C H

II

R E

A C

H I

I

REACH II implemented into a clinical setting

VHA SettingCaregiver Assistance pilot programHome Based Primary Care120 caregiversAdded to normal dutiesR

E A

C H

V A

R E

A C

H V

A

Intervention Goals

Identify and reduce modifiable risk factorsEnhance quality of care of care recipientEnhance emotional and physical well-being of caregiver

R E

A C

H V

AR

E A

C H

V A

InterventionR

E A

C H

V A

R E

A C

H V

A Twelve individual sessions over six months in home and via telephone Five telephone support group sessions Intervention addresses:

EducationSafetyEmotional well beingSelf-careSocial supportPatient problem behaviors/caregiver skills

Twelve individual sessions over six months in home and via telephone Five telephone support group sessions Intervention addresses:

EducationSafetyEmotional well beingSelf-careSocial supportPatient problem behaviors/caregiver skills

Materials

Training ManualInterventionist ManualSupport Group Leader ManualCaregiver Notebook

R E

A C

H V

AR

E A

C H

V A

Behavioral Topics

ActivitiesBathingCombativenessCommunicationConfusionDental CareDepression (patient)DressingDrivingEarly Stage DementiaEatingEnvironmentFeelings (patient)GriefHallucinations/Delusions

Holidays (patient)HospitalizationIncontinenceMedicationsNutritionRepeated QuestionsSafetySexuality (patient)ShadowingSleepingSundowningTelling the Patient/OthersTravelingVisitingWandering

R E

A C

H V

AR

E A

C H

V A

Stress and Coping Topics

Adult Day CareAsking for Help CommunicatingDepression (Caregiver)Early Stage DementiaFeelings (Caregiver)Financial/Legal IssuesGetting Help (Resources)GriefHealthy Lifestyle

Holidays (Caregiver)Making New FriendsPositive ThinkingProblem SolvingSexuality (Caregiver)Stress Management

Signal BreathMusicStretchingPleasant Events

Visiting

R E

A C

H V

AR

E A

C H

V A

Risk Areas, Treatments, and OutcomesRisk Areas, Treatments, and Outcomes

Caregiver Risk Area Intervention Options Outcomes

Safety (driving, Safety (driving, access to weapons, access to weapons, medications, medications, household household obstacles)obstacles)

WanderingWandering

Home assessments Home assessments and alterations; and alterations; patient monitoring patient monitoring devices; removing devices; removing accessaccess

SecuringSecuring doorsdoors, developingdeveloping safesafepathspaths, IDID braceletbracelet

Reduction or Reduction or elimination of elimination of targeted risk areatargeted risk area

Decreased or Decreased or safer wanderingsafer wandering

Schulz et al. Schulz et al. Am J Geriatr Psychiatry.Am J Geriatr Psychiatry. 2004;12:2402004;12:240--249.249.

Certification

ReadingsCentral training Learning Process WorksheetsCoaching

R E

A C

H V

AR

E A

C H

V A

Sites

Albany, NYBath, NYSyracuse, NYWellsville, NYElmira, NYRome, NYNew York City, NYNorthport, NYButler, PAPittsburgh, PAPhiladelphia, PADurham, NCAtlanta GAAugusta, GA

Memphis, TNMt. Home, TNHuntington, WVCincinnati, OHAnn Arbor, MIBattle Creek, MIGrand Rapids, MIHouston, TXSalt Lake City, UT Minneapolis, MNAlbuquerque, NMDenver, CONewington, CTWesthaven, CTSacramento, CA

R E

A C

H V

AR

E A

C H

V A

REACH VA implemented in a social service setting

AoA evidence-based demonstration grantRosalynn Carter Institute, Georgia Southwestern State UniversityAAA aging network service partners delivering intervention and groupsTargeting 150 caregivers in rural Georgia 2 interventionists1 group leaderR

E A

C H

V A

R E

A C

H V

A

REACH VA implemented in a social service setting

AoA evidence-based demonstration grantRosalynn Carter Institute, Georgia Southwestern State UniversityAAA aging network service partners delivering intervention and groups150 caregivers in rural Georgia2 interventionists1 group leader

G E

O R

G I

A

R E

A C

HG

E O

R G

I A

R

E A

C H

Memphis REACH Coordinating Center

MaterialsCentral training CoachingCertificationEvaluation orEvaluation consultation

R E

A C

H V

AR

E A

C H

V A

Memphis REACH Coordinating Center

MaterialsCentral training CoachingCertificationEvaluation orEvaluation consultation

Y O

U R

R E

A C

HY

O U

R R

E A

C H

Staff

Robert Burns, MDCeleste Bursi, MSSWMarshall Graney, PhDBarbara Higgins, MASarah Kennedy, BAJennifer Martindale-Adams, EdD

Pat Miller, MA Linda Nichols, PhDJeff Zuber, MA