Caring for Dementia Patients

In a partnership with the Veterans Administration’s medical centers and local Alzheimer’s Association chapters in Boston and Houston set up a five year trial so that two person care coordinator teams could provide telephone-based support to patients with dementia and their caregivers over a 12 month period. The VA serves more than 570,000 veterans with dementia.

The trial served veterans mostly male averaging 60 and older with a diagnosis of Alzheimer’s disease, or other dementia. The teams addressed medical and nonmedical needs through education, coaching, links to needed resources, and mobilization of an informal care network known as “Partners in Dementia Care”.The two care coordinators collaborated through weekly phone calls and via secure electronic communications. In addition, coordinators and managers across the two sites participated in biweekly calls to share lessons and advice.

The program improved psychosocial outcomes in terms of depression and care-related strain, reduced hospital readmissions, reduced the likelihood of institutional placement for veterans with more severe problems, and provided veterans more access to outpatient services. The program was generally well accepted by the patients, families, physicians, sponsoring partner organizations, and has led to increased caregiver satisfaction with VA services.

The program was developed by researchers at the VA, Benjamin Rose Institute on Aging in Cleveland, Cleveland State University, and Baylor College of Medicine, along with administrators, policy experts, and service providers from organizations across the country including the Alzheimer’s Association.

The planning and development process included identifying partner organizations who had adequate resources and interest in testing innovative models for dementia care, refining existing program protocols, developing a clinical information system that is easy to use, providing training for  care coordinators, and educating the physicians with an emphasis on identifying and referring eligible patients.

The funding sources included the Robert Wood Johnson Foundation, Alzheimer’s Association, VA Houston Center of Excellence, VA South Central Mental Illness Research and Education Center, and the VA’s Health Services Research and Development program.

Today, the program continues to move forward in communities. The Administration on Aging (AoA) recently funded two projects that use the single coordinator version of the program originally used in Cleveland, Georgia, and Tennessee that featured a partnership between Alzheimer’s Tennessee Inc. and Humana.

Several years ago, AoA funded a replication of the program in Ohio that operates outside of a controlled research study. Also, AoA has supported adaptations of the program for individuals with other chronic diseases including older adults with multiple chronic conditions.

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