REACH IIResources for Enhancing Alzheimer’s

Caregiver Health

The Texas Experience

Alan B. Stevens Vernon D. Holleman-Lewis M. Rampy Centennial Chair in Gerontology Scott & White Healthcare

REACH II Clinical Trial

•  Sponsored by the National Institute on Aging (NIA), National Institute of Nursing Research (NINR)

•  Second in a series of multi-site research programs to develop and test effective caregiver interventions

•  Ethnically diverse sample of 642 care recipient/ caregiver dyads in six sites

•  Intensive intervention of home visits and phone calls

•  Standardized assessments at baseline and 6-months

REACH II Intervention

•  Number of therapeutic contacts

•  9 in home, 1.5 hour sessions

•  3 telephone sessions, one-half hour each

•  5 structured telephone support groups

•  Delivery by Interventionist certified in the treatment protocol

•  Bachelor or Master’s in social science disciplines (e.g., psychology, social work)

•  Intervention strategies allowed tailoring of the intervention to meet specific needs of the caregiver

Reach II Intervention Domains

•  Depression

•  Burden

•  Self-care and healthy behaviors

•  Social support

•  Problem behaviors

REACH II Outcomes

•  5 Measures central to caregiver’s quality of life and closely linked to intervention components modeled into a single primary outcome

•  Depression •  Caregiver burden •  Self-care •  Social Support •  Problem Behaviors of the CR •  Clinical Depression

•  Institutional Placement of CR at 6 months

REACH II Implications

•  Intervention had a meaningful impact on quality of life and rates of caregiver depression were halved

•  Translations into real-world settings –  4 Area Agencies on Aging in Alabama (Burgio, et al.)

–  Intervention differed from trial, but the evaluation demonstrated significant pre-post effects on domains similar to the original clinical trial.

–  24 VA medical centers in 15 states (REACH VA, Nichols, et al.) –  Intervention was similar to trial and achieved similar

outcomes.

Scott & White’s Approach

•  Use implementation research methods to embed an evidence-based intervention for family caregivers (Resources for Enhancing Alzheimer’s Caregiver Health II -- REACH II)

•  Leverage characteristics of an integrated healthcare system to target, identify, and enroll family caregivers in need of support

•  Deliver and evaluate the innovative support program on caregiver quality of life indicators

•  Position the Family Caregiver Program as an asset to Scott & White’s Mission and Vision

REACH II Adaptations for the Healthcare Setting

•  Identified champions within the healthcare system to foster identification of caregivers

•  Package REACH II intervention components into a user friendly format, A Caregiver’s Notebook

•  Use REACH II RAM to identify risks and measure outcomes

•  FCP based in an internal medicine primary care clinic for in-person and one-on-one contacts

Accomplishments of Phase I

•  Significant decrease in overall caregiver risks reported by caregivers, including the domains of caregiver stress, burden, and safety.

•  Findings are “in press” at Translational Behavioral Medicine as Implementing an Evidence-based Caregiver Intervention within an Integrated Healthcare System

2009 Rosalynn Carter Leadership in Caregiving Award

Phase II is in Process

•  Family Caregiver Program has been expanded into other Scott & White Healthcare delivery settings (2 hospitals and 26 clinics)

•  Conduct a cluster randomization trial with the REACH II Quality of Life measure as the main outcome measure

– Continue program in Phase I sites (i.e., skills training and support intervention)

– Randomize service regions –  1 skills training and support intervention –  1 education group comparison

Special Thanks from Scott & White Healthcare to our Partners

Implementation of REACH II in a Community-Based Setting: The Tarrant County/Texas Experience

Donald R. Smith

Vice President, Community Development Division, United Way of Tarrant County

Director, Area Agency on Aging

Tarrant County, Texas

•  Largest cities: Fort Worth and Arlington

•  Total Population: 1.8 million

•  County Population: larger than 12 States

•  Third largest County in Texas

•  Gaining on 2nd largest (Dallas)

United Way of Tarrant County

•  The designated Area Agency on Aging

•  One of few United Ways designated

•  Allows for leveraging of AAA federal monies

•  Alignment of Strategic Goals

•  Expansion of services to older adults and caregivers

United Way Strategic Planning Process

•  “Healthy Aging and Independent Living (HAIL)” chosen as focus by UW Strategic Planning Committee – Summer, 2009

•  HAIL Strategic Design Group formed – Sept. 2009

•  Five Meetings – Nov 18, 24, Dec 1, 9 & Jan 12 of 2009

•  Review of evidence-based programs and services

•  Prioritization of strategies and partnerships

Alzheimer’s Disease Identified as a Target

•  Target population ”Mid-Stage ” Alzheimer’s Disease and Family Caregivers

•  Ranking of Strategies

•  Respite Care

•  Caregiver Education and Training

•  Resources for Enhancing Alzheimer’s Caregiver Health (REACH II)

Partnering with Community Organizations to Meet our Goals

•  Alzheimer’s Association: North Central Texas Chapter

•  $200,000 grant awarded July 1, 2010

•  REACH II design and training August, 2010

•  Grant renewed at $300,000 July 1, 2011

•  Probable funding in FY 13

Future Funding for REACH II

•  Re-engineering of Healthy Aging and Independent Living Initiative (Fall of 2011)

•  Expanded program to other chronic conditions

•  Original initiative three years (2010-2012)

•  Pending expansion to ten years (2010-2020)

•  $18.5 million

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HAIL REACH provided by the

Alzheimer’s Association - North Central Texas Chapter

Susanna Luk-Jones, MS Director of Programs and Services

Alzheimer’s Association - North Central Texas Chapter

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About HAIL REACH

•  Funding through the United Way of Tarrant County’s Healthy Aging and Independent Living Initiative

•  Partnering with Easter Seals of North Texas and University of North Texas - Health Science Center as the project evaluator

•  Staffing with Dementia Care Specialists (LPC or LPC-i)

•  Providing REACH II intervention components via counseling and structured skills training to dementia caregivers over a 6-month period

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HAIL REACH Impact Outcomes

Quality of Life Evaluation   Pre and Post intervention assessment   Assesses caregivers’ strength in key areas:

•  Depression •  Caregiver Burden •  Self-Care •  Social Support •  Problem Behaviors/Safety

Prevent premature long-term care placement of the person with dementia

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REACH Enrollment Process

Referral sources: •  Alzheimer’s Association 24/7 Helpline, case

management program and educational programs •  Area Agency on Aging and ADRC •  Home health and hospice agencies

HAIL screening criteria •  Families living in Tarrant County facing a dementia

diagnosis or Early On-set Alzheimer’s

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Client Assessment and Care Plan

Risk Appraisal Measure (RAM) •  16-item questionnaire •  Determines client risk level for caregiver burnout from

low to moderate to high

REACH II Intervention Components tailored to Caregiver’s needs •  Between 4-6 therapeutic sessions •  At least 2 telephone contacts between sessions

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Year 1 August 2010 - June 2011

Staffing •  2 Dementia Care Specialists •  Added third specialist in April 2011

217 Caregivers Enrolled •  435 Home visits •  1,515 Follow-up contacts

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Year 2 July 2011 - February 2012

Staffing •  3 Dementia Care Specialists (3 FTE) •  2 Interns (1 FTE)

233 Caregivers Enrolled •  597 Home visits •  1,932 Follow-up contacts

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Preliminary 20-Month Outcomes

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Preliminary Outcomes of Quality of Life Inventory

•  Clinical impressions indicated that the program is positively impacting caregivers depression, burden, self-care and social support

•  Caregivers reported decrease in problem behaviors

•  Data analysis of the REACH II QoL measure will begin soon

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Lessons Learned

•  Dementia Care Specialists must resist the urge to become social workers for the sake of fidelity

•  Clients need more tangible reminders to focus on the key domains

•  Broad referral base •  Program screening tool •  More consistent & regular program review to

detect and correct problems •  Accountability and on-going support to ensure

fidelity