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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
ACKNOWLEDGEMENTS
• The UCLA and University of Minnesota Clinical and Transla8onal Science Ins8tutes
• Ana Diaz, MD, of Payne Phalen Block Nurse Program, St. Paul, MN
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.
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
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.
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.
PREVIOUS & PRELIMINARY STUDIES: ACCESS
Vickrey, et al. Ann Intern Med. 2006;145 713‐26
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.
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.
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
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
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
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.
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
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.
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
QUESTIONS?
Joseph E. Gaugler, Ph.D.
Phone: 612‐626‐2485 Email: [email protected]
Joshua Chodosh, MD, MSHS
Phone: 310‐268‐3361
Email: [email protected]