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1 Alzheimer’s Disease Coordinated Care for Hispanic and Latino Seniors: Pilot Implementation JOSEPH E. GAUGLER, PH.D. ASSOCIATE PROFESSOR MCKNIGHT PRESIDENTIAL FELLOW SCHOOL OF NURSING UNIVERSITY OF MINNESOTA JOSHUA CHODOSH, MD, MSHS ASSOCIATE PROFESSOR OF MEDICINE DAVID GEFFEN SCHOOL OF MEDICINE AT UCLA VA GREATER LOS ANGELES HEALTH SYSTEM, GRECC ASSISTANT CHIEF OF STAFF/PATIENT SAFETY

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Alzheimer’s Disease Coordinated Care for Hispanic and Latino Seniors: Pilot

Implementation

JOSEPH E. GAUGLER, PH.D. ASSOCIATE PROFESSOR

MCKNIGHT PRESIDENTIAL FELLOW SCHOOL OF NURSING

UNIVERSITY OF MINNESOTA

JOSHUA CHODOSH, MD, MSHS ASSOCIATE PROFESSOR OF MEDICINE

DAVID GEFFEN SCHOOL OF MEDICINE AT UCLA VA GREATER LOS ANGELES HEALTH SYSTEM, GRECC

ASSISTANT CHIEF OF STAFF/PATIENT SAFETY

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ACKNOWLEDGEMENTS

•  The UCLA and University of Minnesota Clinical and Transla8onal Science Ins8tutes 

•  Ana Diaz, MD, of Payne Phalen Block Nurse Program, St. Paul, MN 

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OVERVIEW 

•  Demen8a prevalence is high among US La8no popula8ons and onset is oLen at earlier age 

•  Problems are magnified by poverty and poor access to healthcare services 

•  ADC‐HL is a transla8on of the Alzheimer’s disease Coordinated Care for San Diego Seniors (ACCESS) study (Vickrey, PI) 

•  The ADC‐HL is a community‐centered, demen8a care management protocol designed to reduce caregiver burden and challenging, demen8a‐related symptoms (e.g., behavioral disturbances) in La8no/Hispanic families. 

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OBJECTIVE 

•  To ascertain the feasibility of the Alzheimer’s Disease Coordinated Care for Hispanic and La8no Seniors interven8on (ADC‐HL) in St. Paul, MN.   

•  To develop a care management program with the best opportunity to achieve the greatest relevance and effec8veness for this popula8on 

•  To reduce caregiver burden and challenging, demen8a‐related symptoms (e.g., behavioral disturbances) in La8no/Hispanic families.  

•  To develop strong collabora8ve processes between UM and UCLA for future transla8onal research in demen8a within La8no/Hispanic communi8es 

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SPECIFIC AIMS 

•  Complete a feasibility study of the ADC‐HL with 17 Hispanic or La8no demen8a caregivers that collects informa8on on fidelity of ADC‐HL implementa8on, ADC‐HL uptake by family caregivers, and ADC‐HL impact on everyday caregiver ac8ons/behaviors. 

•  Measure changes in key outcomes that ADC‐HL is designed to improve, including reducing the severity of demen8a symptoms for persons with Memory loss (PWMLs), health service use for PWMLs, and self‐reported family caregiver stress, mood, and quality of family care processes over a 4‐month period. 

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SIGNIFICANCE 

•  Over 5 million individuals in the U.S. have Alzheimer’s disease and related demen8as  

•  Significant burden across families.  •  Prevalence among Hispanic/La8nos is poten8ally higher than 

in other racial/ethnic groups with symptom onset occurring 6‐7 years earlier than in non‐Hispanic/La8nos.  

•  Hispanic/La8no popula8on > 65 yrs will be the largest racial/ethnic minority among older adults in the U.S. by 2019 

•  19.8% of U.S. older adults by 2050.  •  Lack of accultura8on and socioeconomic barriers = 

exacerbated demen8a care in Hispanic/La8no communi8es.  

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PREVIOUS & PRELIMINARY STUDIES: ACCESS

Vickrey, et al. Ann Intern Med. 2006;145 713‐26 

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PREVIOUS & PRELIMINARY STUDIES: ACCESS PATIENT AND CAREGIVER HEALTH 

8

Usual Care Mean 

Interven8on Mean 

Adjusted Between‐Group 

Difference 

P ‐Value 

Pa8ent’s health related quality of life (0‐1 range) 

0.03  0.10  0.06  0.03 

Overall quality of healthcare (0‐10 range) 

7.9  8.2  0.5  0.003 

Caregiver Confidence in Caregiving (0‐100 range) 

60  67  6.4  0.001 

Caregiving‐anributable Health Strain (0‐100 range) 

60  64  4.3  0.06 

* Higher scores mean bener outcomes  Vickrey, et al. Annals 2006;145:713‐726. 

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PREVIOUS & PRELIMINARY STUDIES: ACCESS Teams Produce Bener Quality

DCM= Demen8a Care Manager; Community= All 3 components  together  Chodosh, et al. Am J Man Care 2012;18:85‐94. 

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PREVIOUS & PRELIMINARY STUDIES: V‐CAMP 

Ac#ons Taken  % Referrals  Requested% 

Comprehensive assessment  100%  62.7% 

Blood pressure management  32.8%  0% 

Hearing assessment/interven8on  26.9%  0% 

New demen8a diagnosis  26.9%  62.7% 

Exercise rou8ne provided  26.9%  0% 

Physical therapy ordered  23.9%  0% 

Advance care planning  23.9%  0% 

Driving recommenda8ons  22.4%  0% 

An8cholinergic/Benzo reduc8on  22.4%  0% 

Incon8nence assessment / therapy  19.4%  0% 

ID bracelet provided  17.9%  0% 

Sleep management  16.4%  0% 

ACh‐I Discon8nued  16.4%  0%  10

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PREVIOUS & PRELIMINARY STUDIES: Compara8ve Effec8veness of Demen8a Care Strategies in Underserved Communi8es 

•  Care management comparing community‐based (in person) versus telephone‐only care 

•  San Fernando Valley – Predominantly La8no immigrant underserved community 

•  Preliminary findings:   Large service needs   Vast educa8onal gaps   Socioeconomic pressures   Immigra8on challenges   Percep8on of need differs between caregiver and care manager   Enrollment challenges   Even larger follow‐up challenges 

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ADDITIONAL POINTS OF INNOVATION

•  A focus on demen8a care in an underserved community •  Use of mixed methods design •  Applica8on of new assessment tools for greater efficiency but 

needing feedback from caregivers / care managers •  Restructuring of care management process to achieve greater 

clarity for caregivers immersed in the process, care managers learning the process, and for educa8ng others 

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APPROACH

•  Phase I. Training. Videoconference training of Dr. Diaz over a 2 month period

•  Phase II. Feasibility study. Enroll 17 family caregivers of persons with memory loss from PPBN in east St. Paul, MN 1. Baseline assessment (RAM, HABC-Monitor, service use, use of

anti-dementia drugs, sociodemographics) 2. Implementation of ADC-HL protocol. 3. 4-Month assessment (RAM, HABC-Monitor, service use, use of

anti-dementia drugs) 4. Post-ADC-HL focus group to examine ADC-HL uptake and

impact as perceived by family caregiver participants.

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ANALYSIS

•  Feasibility analysis: Specific Aim 1.   Univariate, descriptive statistics will be conducted to examine

empirical process data (e.g., duration and frequency of ADC-HL care coordination use) to examine the feasibility of the ADC-HL.

  In addition, thematic content analysis of focus group data will take place to determine barriers to ADC-HL use as well as why the ADC-HL does or does not work for participants

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ANALYSIS

•  Descriptive longitudinal analysis: Specific Aim 2.   Cronbach's alpha (α) estimates will examine reliability of all

summed measures.   Each outcome variable will be examined to determine if skewness

exists or outliers are present. Normal probability plots and histograms of each dependent variable will be analyzed.

  Data available at baseline and 4 months will also allow for longitudinal analyses of rate of change in key outcomes: i.e., the various domains assessed by the RAM and HABC-Monitor, health service use, and acetylcholinesterase inhibitor use.

  A classic repeated measures analysis of variance will be conducted using SPSS.

  Additional analyses will determine if covariates (e.g., sociodemographics) are correlated with change in ADC-HL outcomes during the 4-month study period.

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FUTURE PLANS

•  Preliminary results will support translational research proposal in response to PA-11-123: Translational Research to Help Older Adults Maintain their Health and Independence in the Community R01.

•  Feasibility data from this project along with Los Angeles-based comparative effectiveness evaluation will provide strong preliminary data for a multi-site translational project of ADC-HL.

•  We will leverage several existing University of Minnesota/UCLA CTSI resources.   Delaware Clinical Research Unit   Communuity Engagement for Health at the University of

Minnesota and UCLA’s sister office   The CTSI Biostatistical Design and Analysis Center will be

utilized for the subsequent R01 proposal

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QUESTIONS? 

Joseph E. Gaugler, Ph.D. 

Phone: 612‐626‐2485 Email: [email protected] 

Joshua Chodosh, MD, MSHS 

Phone: 310‐268‐3361 

Email: [email protected]