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HOSPITAL 2 HOMESTAKEHOLDER PLANNING SUMMIT ~ FEBRUARY 26, 2020DEMENTIA CAPABLE CARE TRANSITIONS: BETTER CARE AND BETTER OUTCOMES

#Stakeholder2020 hospital2home.org

Jeffrey B. Klein, FACHE

President & CEO Nevada Senior Services Inc.

Progress ReportHOSPITAL 2 HOME: Dementia Capable Care Transitions

Grant Awarded

Nevada Aging and Disability Services Division (Pilot Program)

Administration on Community Living (Development Project) Primary Goal: Improving health outcomes & quality of life with individuals

living with dementia

Objective 1: Deliver evidenced-based care transitions model and post care transitions services within a community-based dementia capable framework

Objective 2: Offer short-term intensive respite (respite coaching) to care partners for up to 30 days following hospital discharge

Objective 3: Provide dementia capable education and training to hospital staff to better service patients with ADRD and their care partners

Service PopulationCriteria Defined by grant requirements and stakeholder input

Currently Serving individuals Living with ADRD (diagnosed or self-identified) of all ages

Individuals with Intellectual or Developmental Disabilities (I/DD) at high risk for ADRD

Currently hospitalized for any medical condition

Lives at home alone

Care Partner and Person with ADRD reside together

Discharge from hospital to home

OR

Service Delivery – Care Transitions

Deliver an evidence-based Transition of Care Program – The Bridge Model, Rush University Medical Center

Collaborate with hospitals to ensure seamless continuum of health and community care across settings

Deliver Post Care Transitions wrap around services

HOSPITAL2HOME: Dementia Capable Care Transitions

The Elements Delivered: 30 Days Post-Discharge Bridge Model – evidence-based care

transitions Provide Respite Coaching – intensive supports

& break to caregiver Wrap-around services connectivity

Model Enhancement:Post Care Transitions Service Delivery

30-day post assessment Goal: Supporting patient and caregiver to continue

to engage in other services for continued support Personalized Care Plans Connection to internal and external information and

referrals

Model Enhancement:Post Care Transitions Service Delivery

External

Referrals to community public and private resources Long term supportive resources Basic need programs Caregiver education and support services

Dementia Education and Training

Dealing with Dementia4 HOUR WORKSHOP FOR PROFESSIONAL AND

FAMILY CAREGIVERS

Caregiver Education Series TOPICS INCLUDING ACCESSING RESOURCES, FUTURE

PLANNING and BRAIN HEALTH

Caring For You, Caring For Me

10 HOUR WORKSHOP FOR PROFESSIONAL AND FAMILY CAREGIVERS

Thoughtful Hospitalization®

A 90 MINUTE WORKSHOP FOR CAREGIVERS TO PREPARE FOR POSSIBLE HOSPITALIZATION AND

UNDERSTANDING CAREGIVER RIGHTS

Thinking About ThinkingINFORMATIVE SEMINAR THAT ADDRESSES THE KEY

ROLE THAT COGNITION PLAYS IN PATIENT SUCCESS IN THE ACUTE CARE ENVIRONMENT

Progress Report Highlights

Participating Organizations

January 2018 19 January 2019 37 January 2020 69

Progress Report Highlights

Persons Served To Date = 290Program Enrollment To Date = 78Currently Pending Discharge = 15Program Readmissions = 2

Progress Report HighlightsRecruited and trained an outstanding teamRefined the model working with Cognitive Solutions & BridgeDeveloped database and analytic tools

Presented “Thoughtful Hospitalizations” to caregiver groupsPresented “Thinking About Thinking” two hospital clinical & administrative leadershipPresentations at regional and national conferences and meetings

Benefit of Community Partnerships

Enhances service delivery Provides expertise and support Streamlines process and procedures Enhances collaboration and communication Increases engagement of patient and caregivers Encourages best person-centered and best practices

A reminder of our mission.

Mike Splaine, Splaine Consulting

Facilitator’s Conference Overview

9:00 to 9:45 AM Dementia Initiatives: A National ViewErin Long, MSW Administration on Community Living

9:45 to 10:30 AM Outcomes & Impact: NevadaReadmission Rates & H2H Cost SavingsJerry Reeves MD Medical Director, Comagine Health

10:30 to 10:45 AM Break

10:45 to 11:15 AM The Health Systems View: Experience & OpportunityGina Pierotti-Buthman RN, MSN, ACHRN, Regional Director Care Management, Valley Health System

11:15 to 12:00 PM Raising Community Awareness of Hospital2HomeKate Gordon MSW, Splaine Consulting

12:00 to 1:00 PM Lunch

1:00 to 1:30 PM Hospital2Home: The Clinician RoleYvonne M. Randall, EdD, OTR/L, FAOTA

1:30 to 2:00 PM Dementia Capable Care Transitions: OutcomesZebbedia Gibb, Ph.D., Sanford Center for Aging in the University of Nevada, Reno School of Medicine

2:00 to 3:00 PM Stakeholder Workgroups

3:00 to 3:15 PM Break

3:15 to 3:45 PM Stakeholder Group Reports

3:45 to 4:15 PM Action Plans/Round Robin SessionMike Splaine

4:15 to 4:20 PM Facilitator Summation, Mike Splaine

4:20 to 4:30 PM Closing Remarks, Jeffrey Klein

AGENDA

Session 1

Public Policy/SystemsThis group will discuss the policy climate for issues affecting individuals living with dementia and caregivers and identify possible policy actions and opportunities.

Session 2

Home Sweet HomeTypically, an older person will return home after a hospital stay with new medications, therapy orders, new agencies in their lives offering services. This group will brainstorm ways we can help families better navigate the immediate post hospital information and rehabilitation crush.

Session 3

Sustainability Solutions Hospital2Home has become a tested cluster of services that are valued by the persons and families served—but it has been funded initially by grant funds. This group will brainstorm possible sources of ongoing funding and support for care transitions.

STAKEHOLDER WORKGROUPS2:00 to 3:00PM

February 2020

Building Dementia Capability in Nevada and

Across the NationErin Long, MSWAdministration on AgingAdministration for Community Living

Page

The Alzheimer’s Public Health Crisis

Where are we active? (January 2020)

Program Outcomes Highlights

AK

CA

OR

WA

AZ

NV

WYID

MT ND

SD

COUT

NM

IA

AR

MO

LA

OK

KS

NE

TX

ALMS

IL

WIMN

GA

OH

KY

TN

IN

MI

SC

PA

NY

ME

VA

NC

FL

NJ

WV

PR

CTRI

MD

MA

NH

VT

HI

DE - 1DC - 1

• HCBS grantees: AAAs/COGs/ADRC, ADRD specific service providers, City & County governments, hospital systems, senior centers, and university based service providers.

• Over 50,000 professionals reported trained since 2018!

ACL State and Community Programs Designed to:

• Expand dementia-capability of states and communities;• Improve and expand on person-centered care for individuals

living with Alzheimer’s and dementia, and• Support paid and unpaid caregivers through provision of

education, training and tools.

Community Grantees Filling Identified Gaps

• Provision of supportive services to persons living alone with ADRD in the community

• Improvement of the quality and effectiveness of programs and services dedicated to individuals living with intellectual and developmental disabilities with ADRD or those at high risk of developing ADRD

• Delivery of behavioral symptom management training and expert consultations for family caregivers.

Dementia Capable Services• Dementia care training for health professionals in diagnosis protocols• Dementia capability in the IDD community• Dementia capable care coordination training• Awareness training for community service workers• Training of hospital system care coordination staff

Dementia Capable Communities• Pilot “Dementia Capable Community” grant programs in 16 communities• “Dementia Friendly Business” campaign for businesses, customer and

employee support• Dementia Friendly Community projects• Community gatekeeper programs to identify possible cognitive

impairment.

Early Diagnosis• Development of screening for early identification of dementia and their

family caregivers• Increase in access to evidence-informed early stage memory loss

programs and behavioral support• Community based multi-disciplinary group training program for individuals

with early diagnosis, mild cognitive impairment

Independent Living• Implementation of “Connections” intervention to match individuals’

functional levels with activities to sustain meaningful engagement in life • Launching of a money management program to assist those with ADRD

with finances• Implementation of community gatekeeper programs• Referral program partnering with nurses in low income housing complexes

Engagement of Faith–Based Community• Outreach and training for clergy and faith-based communities• Faith Care Connection program in network of churches

Emergency Preparedness• In-person and online dementia training to first responders• Training videos for law enforcement• Friendly visitor EMT program

ACL ADRD Program Activities

Nevada’s Local and National Partners

CARE TRANSITIONSHospital2Home

• Partnering with hospitals– Educating medical staff

• Care transitions• Dementia Education• Best practices in supporting those with ADRD or at risk

• Respite Coaching– 30 Day intensive supports for caregivers and care recipients:

• Companionship• Errands• Meal Preparation• Behavioral symptom management education, and • Other supports

Nevada Dementia Friendly Communities

• Piloted in Seven Communities– Urban, Rural and Tribal– Community developed and driven goals

• i.e. Dementia awareness, community education and stigma reduction

– Dementia Friendly Nevada website (LINK) – Dementia Friends Program

Alzheimer’s Disease Programs Initiative (ADPI)

• State and Community Grant Program– Combines State (ADSSP) and Community (ADI-SSS) Programs under a single initiative;

• Dementia specific evidence-based or evidence-informed interventions• Robust, third party, evaluation, • 50% of total budget to direct service provision, and • 25% cost share

– 2020 Applications due April 20;• National Alzheimer’s Call Center

– In year 2 of 5 year grant– $1.2M toward support of the Alzheimer’s Association 24/7 call center

Administration for Community LivingFUNDING OPPORTUNITY ANNOUNCEMENT

Alzheimer's Disease Programs Initiative - Grants to States and Communities (Grants.gov SEARCH ADPI )

HHS-2020-ACL-AOA-ADPI-0379DUE DATE: April 20, 2020

Estimated Total Funding: $19,195,102Expected Number of Awards: 24Award Ceiling: $1,000,000 Per Project PeriodAward Floor: $400,000 Per Project Period

https://www.grants.gov/web/grants/view-opportunity.html?oppId=316879

National Alzheimer’s and Dementia Resource Center(NADRC)

www.nadrc.acl.hhs.gov

• Technical Assistance to present, past and future grantees and stakeholders;• Website makes issue briefs, toolkits, case studies, reports and grantee

products, available to everyone;• Facilitation of annual webinar series.

http://www.nadrc.acl.hhs.gov/

THANK YOU!

Erin Long, MSWOffice of Supportive and Caregiver Services

Administration on AgingAdministration for Community Living

US Department of Health and Human [email protected]

202-795-7389

mailto:[email protected]

Car ing for the Fra i l -Fa i lures and Successes

Jerry Reeves MD, Medical Director, Comagine Health and HealtHIE Nevada

Goals

• Frailty defined • Prevalence• Consequences• Care - Measures of Success• Agents of Change• Best Practices• Lessons Learned

Frailty - Any 2

• Dementia• 5 Million Americans and 16 Million Caregivers• Only 45% of Patients and Caregivers Aware of the Diagnosis

• 5+ Chronic Conditions• 2+ Admissions in the Past 6 Months• 3+ Emergency Department Visits in the Past 6 Months• Consistently Missed Office Visits• Difficulty Leaving the Home

Prevalence and Consequences• 6% of Medicare FFS Beneficiaries (55% increase in Nevada in 10 years)• 30% of all Medicare Spend• 24% of Medicare Hospitalizations

• Falls > Heart Disease > Gastrointestinal > Pneumonia > Delirium• 46% of Medicare Readmissions• 38% of New Long-Term Care Institutionalizations• 23% of Deaths (211% increase in Nevada in 14 years)• Annual Spending Growth

• Dementia= 4% per year• Anxiety & Depression (Despair)= 7% per year

Hospital Dementia Care• 25% of Elderly Have Dementia• Rarely Diagnosed• Delirium• Falls• Dehydration• Inadequate Nutrition• Untreated Pain• Medication Problems

• Functional Decline• Restrained• Post-Discharge Problems

• Medication Errors• Infections• Falls• Safety Concerns• Psychosis• Despair• Suicide

Most Expensive Conditions

http://content.healthaffairs.org/content/35/6/113039

http://content.healthaffairs.org/content/35/6/1130

Hospitalization Trends Nevada

Nevada Hospital Readmissions

41

Chronic Conditions and ER Visits

http://www.njha.com/media/546633/CHART-Chronic-Conditions.pdf

http://www.njha.com/media/546633/CHART-Chronic-Conditions.pdf

Measures of Success• Clinical Quality

• Coordinated Preference Sensitive Care• Better Function- Less Decline

• Affordability• Savings• Least Restrictive Environment

• Exceptional Patient Experience• Patient• Caregiver

• Clinician Well-Being

Cancer, diabetes, emphysema, high cholesterol, HIV/AIDS, hypertension, ischemic heart disease, stroke, arthritis, asthma, gall bladder disease, stomach ulcers, back problems, Alzheimer's disease and other dementias, and depression.

“Between the care that we have and the care that we could have lies not just a gap but a chasm…”

1. Focus on 15 priority conditions

2. Bring together the stakeholders

3. Implement these steps

Health care organizations, clinicians, purchasers

(1) organize evidence-based care processes consistent with best practices (2) organize major prevention programs to target key health risk behaviors (3) develop the information infrastructure needed to support the provision of care (4) align the incentives inherent in payment and accountability processes with the

goal of quality improvement

Crossing the Quality Chasm 2001

https://www.ncbi.nlm.nih.gov/books/NBK222271/

Agents of Change

• Investment• Leadership Commitment and Budget

• Work Force Pipeline• Address Social Determinants• Patient & Caregiver Engagement• Communication

Frailty Care Best Practices

• Community Engagement• Workforce Development• Community Health Information Exchange• Hospital System Care• Hospital2Home Dementia Capable Care

Transitions• Trained Staff – Dementia Curriculum • Caregiver Support/ Respite Care• Home Modification/ Durable Medical

Equipment• Personal Care Assistance

• In Home Care Management

Support Networks

• Nevada Divn Welfare & Supportive Services• https://dwss.nv.gov/Contact/Welfare/

• Catholic Charities• https://www.catholiccharities.com/service_details/social-services/

• Nevada 211• https://www.nevada211.org/

• Nevada Coalition for Suicide Prevention• https://nvsuicideprevention.org/

• Nevada Senior Services• http://www.nevadaseniorservices.org/

48

https://dwss.nv.gov/Contact/Welfare/

https://www.catholiccharities.com/service_details/social-services/

https://www.nevada211.org/

https://nvsuicideprevention.org/

http://www.nevadaseniorservices.org/

Recruit and Retain TeamsWork Force Development

Health Information Exchange ValueChronic Disease Management

• Enables faster and easier understanding of your patients’ ongoing needs • Enables exchange of clinical information • Enhances reimbursements for care coordination and quality measures • Decreases care delays and increases patient loyalty• Minimizes administrative burden of electronic record documentation • Reduces avoidable hospitalizations • Decreases duplicate testing • Improves care coordination

Best Practices – Hospital SystemsReducing Multiple Chronic Conditions Readmissions

Best Practices - ResultsHospital2Home Dementia Capable Care Transitions

• Quality of Life • Patient – Activities of Daily Living 13% Better• Caregivers- Burden Score 55% Lower

• Hospitalizations – 47% Lower • Customer Experience

• Would Recommend to Others - 83% Strongly Agree• Services Met Needs – 75% Strongly Agree

Best Practices – ResultsIndependence at Home CMS Demonstration

• Clinician Experience• 82% of Practices Retained 5 Years

• Savings• $1,840 per Patient per Year Average• $500 per Beneficiary per Month – Top 25% of Practices

• Much Better Than ACOs• 12-Fold the Pioneer and Next Generation ACO Savings• >3-Fold Higher Practices Retained 5 Years vs Pioneer ACO

Best Practices – ResultsCrucial Care Without Walls

• Savings• Decreased Total Costs by >26.5%

• Quality• Reduced Hospital Readmissions by 52%• Reduced Unhealthy Days

• Patient Experience• Increased Patient Satisfaction to 95% Net Promoter Score

Summary

• Manifestations of Frailty• Prevalence and Consequences• Measures of Successful Care• Agents of Change• Results of Best Practices

• Caring for the Frail Is A Team Sport

Questions?

VALLEY HEALTH SYSTEM & NEVADA SENIOR SERVICES COLLABORATIVE PROGRAM –BRIDGE – ONE STAKEHOLDERS EXPERIENCEGina Pierotti-Buthman RN, MSN, ACHRN – VHS Regional Director Care Management/Social Services/Utilization Management

INTRODUCTION

• Care transitions for persons with Alzheimer's and dementia, represents daunting challenges for the individual, their family caregiver, the health care delivery system and often the communities in which the person resides. Older adults with Alzheimer’s/dementia have higher skilled nursing facility use, greater hospital and home health care utilization, and more transitions per person per year.

• A program of Care Transitions designed to address the difficult challenges posed by patients with cognitive impairment, and their family caregivers, will help these high-risk older adults with memory concerns, transition from the hospital back their homes while providing the much needed respite type care necessary for their caregivers to continue provision of services necessary to maintain this population.

PROGRAM INITIATIVES IN REVIEWKey elements of the collaboration:

Nevada Senior Services would provide:

• Bridge Care Transitions Intervention (enhanced for dementia)

• Bridge certified interventionist to deliver care transitions services to identified VHS patients working in close coordination with the VHS team.

• Dementia specific training for VHS personnel including modified version of “Caring For You, Caring For Me”, “Thoughtful Hospitalizations”, “Thinking About Thinking” and “Delirium”.

• Outcome tracking system utilizing nationally normed scales.

• In-home respite for care transitions clients in the pilot.

• Follow-on menu of evidence-based interventions:• Care Consultation (telephone enabled caregiver support)• RCI REACH (1:1 in-home 12 session intervention for dementia caregivers)• Skills2Care (OT delivered 5 session in-home safety & skills building for dementia caregivers)• Home Safety Modifications

• Integration with network of community-based services through the Aging and Disability Resource Center

Valley Health System would provide:

• Participation in program implementation planning

• Participation in protocol, policy and procedure development

• Designated personnel to participate in the pilot including care management, social work and emergency department.

• Patient identification and assistance in coordination with patients, family caregivers and physicians.

• Participation in program evaluation.

• Collaboration in developing a self-sustaining model including the potential of billing under MACRA which would enhance both physician and hospital profiles for reimbursement under Medicare.

WORKFLOW

BRIDGE MODEL TEMPLATE

EXPECTED OUTCOMES• Reduced readmission rates• Reduced emergency department visits• Increased health indicators• Decreased caregiver burden• Increased caregiver coping• Decreased depression• Enhanced patient and caregiver activation

PROGRAM EXPANSION AND ENHANCEMENT

• Hospital to Home Integration: Best Practices in hospital care and home transition for patients with dementia, have shown to reduce readmissions and mitigate potentials for poor outcomes.

• Unfortunately, evidence-based care transition models have routinely excluded patient with dementia and often have limited interactions with caregivers.

• Nevada Senior Services has developed a comprehensive array of services that serve as a model for success.

• VHS has taken that opportunity and collaborates for this patient population with NSS to ensure best practice through the continuum.

NEW INITIATIVE

• A direct discharge from hospital to Adult Day Health Center. • Adult Day Care Center of Las Vegas and Henderson (ADCC), a program of

NSS, is a health and medical adult day model providing medication management, nursing care, socialization, respite care, occupation therapy, meals, health screenings, and exercise.

• ADCC’s can accommodate health and wellness needs as ordered by physician and can be delivered on site including: home health, occupational therapy, physical therapy etc.

PROGRAM EXPANSION AND ENHANCEMENT

NEXT STEPS: MEASURING SUCCESS

PILOT

NEXT STEPS: MEASURING SUCCESS

Count of Participation

Years Enrolled Enrolled Complete

EnrolledNon-complete Not Enrolled Pending

Service Delivered

Not EnrolledGrand Total

2018 0 10 3 22 0 12 47

2019 7 37 16 116 1 38 215

2020 5 0 0 9 14 0 28

Grand Total 12 47 19 147 15 50 290

Count of Readmission

Years No Readmission Different DRG Same DRG Grand Total

2018 46 1 0 47

2019 207 8 0 215

2020 27 1 0 28

Grand Total 280 10 0 290

EXPANSION PROJECT ~ July 2018 to Present

NEXT STEPS: MEASURING SUCCESSDRAMATIC INCREASE IN REFERRAL PARTNERS

ADCC HendersonADCC Las VegasAlzheimer’s AssociationBaby BoomersBrightOnCentennial Hills HospitalCleveland Clinic - Lou Ruvo Center for Brain HealthCommunity OtherDesert Springs HospitalGAPHealthcare PartnersHenderson Fire Department

Henderson HospitalLas VentanasMountain View HospitalNSS CCRC NSS RAMP ProgramNSS Respite ProgramOpportunity VillageOptumSouthern Nevada CHIP'sSpring Valley HospitalSummerlin HospitalVA Southern Nevada Healthcare SystemValley Hospital

QUESTIONS?

Thank you for your Participation and Engagement

Kate Gordon MSW, Splaine Consulting

Raising Community Awareness of Hospital2Home

Mission: Hospital2Home

Objective: Program Sustainability

Outcome: People will ask for the service by name

Task: Brainstorm 3 -4 ways to reach consumers directly to get them to start asking

Output: Use an ORANGE Post It to record your ideas** Put group member names on back

Hospital 2 Home:The Clinician Role

Nevada Senior Services, Inc.Stakeholder Planning SummitDementia Capable Care Transitions: Better Care & Better Outcomes

February 26, 2020

Yvonne M. Randall, EdD, MHA, OTR/L, FAOTA

Nevada Senior Services, Inc.

Occupational Therapy

Comprehensive Geriatric

Assessment (GAP)

RAMP(Renovate, Assessible,

Mobility, Prevention)

Skills2Care® Program

Skills2Care®-Cathy Piersol, PhD, OTR/L & Adel Herge,

OTD

Evidence supports the impact of this intervention including a randomized controlled trial with 202 dementia caregivers (Gitlin et al. 2001)

Five, 90-minute visits with

Occupational Therapist

Education,Skill Building, &

Environment

Home Based Intervention

Hospital 2 Home:

The Next Phase for Occupational Therapy &

Nevada Senior Services, Inc.

Clinic/hospital-based therapy does not consistently work with persons living with dementia and their caregivers

Care of Persons in their Environments (COPE) -Laura Gitlin, PhD et al.

Evidence of outcomes noted for caregivers through a randomized experimental study (Gitlin, L.N., et al. 2010).

In-person caregiver education

Supports Physical Function & Quality

of LifeAssessmentEducation

Training

Action Plan for Targeted Concerns

Occupational Therapy &

Advance Practice Nurse

COPEOccupational Therapy & Advanced Nurse

AssessmentOT

PersonCaregiverEnvironment

ImplementationOT

Stress ReductionProblem solvingCOPE Rx

GeneralizationOT

Strategies used for future

1 2 3 4 5 6 7 8 9 10

Home Visit

APRN

Telephone Call

APRN

Tailored Activity Program (TAP)-Laura Gitlin, PhD, et al. (2009)

Results – caregivers reported high confidence in using activities, less upset with behavioral symptoms, enhanced skills, and personal control

Activities Customized to

Individual

Goal: Reduce Behavioral

Symptoms & Caregiver Burden

Home Based Occupational

Therapy

TAP Activity Domains

Reminiscence and Photo Activities

IADL/ Household

Games & Recreation

Arts & Crafts

Exercise/ Physical Activity

Videos and Music

170 activitiestailored to match cognitiveabilities

Minimizeexternaldemandsfor theperson livingwithdementia

TAPOccupational Therapy

Assessment Introduction of Techniques

Generalize Strategies

1 2 3 4 5Home visit

or Telephone

6Home visit

or Telephone

7Home visit

or Telephone

8

Skills2Care®, COPE, and TAP

All three programs require specialized training and certification to implement

Current training sites: Thomas Jefferson University & Drexel University

Ultimately, the goal is to match activities to the persons

cognitive level.

Reference Gitlin, L.N., Arthur, P., Piersol, C., Hessels, V., Wu, S.S., Dai., Y., & Mann,

W.C. (2017). Targeting behavioral symptoms and functional decline in dementia: A randomized clinical trial. Journal of the American Geriatric Society, 66(2), 2-7.

Gitlin, L. N., Corcoran, M., Winter, L., Boyce, A., & Hauck, W. W. (2001). A randomized, controlled trial of a home environmental intervention: Effect on efficacy and upset in caregivers and on daily function of persons with dementia. The Gerontologist, 41, 4-14.

Gitlin, L.N., Winter, L., Earland, T.V., Herge, E.A., Chernett, N.L., et al. (2009). The tailored activity program to reduce behavioral symptoms in individuals with dementia: Feasibility, acceptability, and replication potential. The Gerontologist, 49 (3), 428-439.

Gitlin, L. N., Winter, L., Dennis, M. P., Hodgson, N., & Hauck, W. W. (2010). A bio-behavioral home-based intervention and the well-being of patients with dementia and their caregivers: The COPE randomized trial. Journal of the American Medical Association, 304(9), 983-991.

http://med.unr.edu/aging

Evaluation: Why Pay Attention to the Man Behind The Curtain?

Zebbedia Gibb, Ph.D.

Evaluation: Why

• Programs typically have:

– Preconceived ideas of what the client population will look like

– Preconceived ideas of what the client will experience• E.g., handbooks of how clients should be greeted / treated

– Preconceived ideas of team member / provider interaction with program materials

• E.g., data collection forms, data entry methods

Evaluation: Why

• Programs typically have:– Preconceived ideas of how the client will interact with the program

• E.g., client flow

– Amorphous, indistinct goals related to the program outcomes • E.g., increase quality of life

– Preconceived ideas of what the client will get out of the experience• E.g., what are the expected outcomes

Evaluation: Why

• Evaluation:

– Measures the client demographics• Helps Identify if outreach is working / needed

– Directly measures the client experience• E.g., client / provider interaction, environmental concerns of clients

– Directly measures the provider experience• E.g., problems with data collection forms

Evaluation: Why

• Evaluation:

– Directly measures how the client interacts with the program• E.g., where the client is initiating contact

– Can help define specific, measurable programmatic goals• E.g., Quality of life as related to their experience of a chronic condition

– Directly measures the expected outcomes and can identify new ones• E.g., helps determine if the client is experiencing the intended impact of the program

http://www.unr.edu/sanford

BRIDGE EVALUATION SUMMARY

BRIDGE Evaluation: Items Measured

• Care Recipient:– 30-day Re-Hospitalization– Self-reported health– Quality of Life (QOL-AD)

• Care Provider– Caregiver Burden (Zarit Caregiver Burden Scale)– Likelihood of Long-Term Care Placement– Program Satisfaction

BRIDGE Evaluation: Care Recipient

• Who were the care recipients (n = 34)?– Majority non-Hispanic White (n = 19)– Female (n = 18)– Age = 79.5– Homebound (n = 29)– Not Living alone (n = 31)


Expected 30 Day Rehospitalization Rate1

82

18

No - Not Readmitted Yes - Readmitted

30 Day Observed Rehospitalization Rate

89.7

10.3

No - NotReadmitted

1Lin, P-J., Zhong, Y., Fillit, H.M., Cohen, J.T., Neuman, P.J. (2017)


27.3

13.3

0

21.2 23.320

36.4

20

33.3

12.1

40

33.3

3 3.3

13.3

0

10

20

30

40

50

Intial Intake 30-Day 3-Month

Poor Fair Good Very Good Excellent

Percent of Respondents Reporting Health Status. Initial interview n = 33, 30-day n = 30, 3-month n = 15


Mean Quality of Life (QOL-AD) Score. Initial interview n = 30, 30-day n = 33, 3-month n = 15.

28.3632.13 32.8

10

20

30

40

50

Initial Intake 30-Day 3-Month

BRIDGE Evaluation: Care Giver

• Who were the care givers (n = 27)?– non-Hispanic White (n = 10)– Female (n = 21)– Age: 58.9


Mean Zarit Caregiver Burden Score. Initial Interview n = 27, 30-day n = 23, 3-month n = 13.

6.74

4.13

3

0

5

10



Mean likelihood of Long-Term Care Placement. Initial interview n = 27, 30-day n = 23, 3-month n = 13.

1.561.09

0.85

0

1

2

3

4

5



Percent reporting Never / Rarely on Select LTC Placement Questions.

85.2% 85.2%91.3% 91.3%92.3% 92.3%

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

Consider LTC Placement Better Off in Nursing Home

Initial

1-Month

3-Month

BRIDGE Evaluation: Overall Experience

Percent reporting Strongly Agree / Agree with Each Statement. n = 12

42%58%

83% 83%75% 75%

83%

58%42%

17% 17%25% 25%

17%

0%10%20%30%40%50%60%70%80%90%

100%

Strongly Agree

Agree

BRIDGE Evaluation: Overall Findings

• Program was able to produce a rehospitalization rate that was 47% below expected (10.3% v. 18%)

• Program participants reported reduced care giver burden at both 30 days and 3 months

• Program participants reported lower likelihood of long-term care placement

Comments and Questions?

Thank you!

Session 1

Public Policy/SystemsThis group will discuss the policy climate for issues affecting individuals living with dementia and caregivers and identify possible policy actions and opportunities.

Session 2

Home Sweet HomeTypically, an older person will return home after a hospital stay with new medications, therapy orders, new agencies in their lives offering services. This group will brainstorm ways we can help families better navigate the immediate post hospital information and rehabilitation crush.

Session 3

Sustainability Solutions Hospital2Home has become a tested cluster of services that are valued by the persons and families served—but it has been funded initially by grant funds. This group will brainstorm possible sources of ongoing funding and support for care transitions.

STAKEHOLDER WORKGROUPS2:00 to 3:00PM

STAKEHOLDERGROUP REPORTS


Health Care

Mobility

Socialization

Nutrition

Housing

Advocacy

AGINGNETWORK

PLEASE WATCH FOR

ENGAGING WITH AGING

OCTOBER 2020

THANK YOU FOR ATTENDING!#Stakeholder2020 hospital2home.org

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