Catherine A. Alder

Implementing Innovative Models of Dementia Care: The Healthy Aging Brain Center

Background: Recent randomized controlled trials have demonstrated the effectiveness of the collaborative dementia care model targeting both the patients suffering from dementia and their informal caregivers. Objective: To implement a sustainable collaborative dementia care program in a public health care system in Indianapolis. Methods: We used the framework of Complex Adaptive System and the tool of the Reflective Adaptive Process to translate the results of the dementia care trial into the Healthy Aging Brain Center (HABC). Results: Within its first year of operation, the HABC delivered 528 visits to serve 208 patients and 176 informal caregivers. The mean age of HABC patients was 73.8 (standard deviation, SD 9.5), 40% were African-Americans, 42% had less than high school education, 14% had normal cognitive status, 39% received a diagnosis of mild cognitive impairment, and 46% were diagnosed with dementia. Within 12 months of the initial HABC visit, 28% of patients had at least one visit to an emergency room (ER) and 14% were hospitalized with a mean length of stay of five days. The rate of a one-week ER revisit was 14% and the 30-day rehospitalization rate was 11%. Only 5% of HABC patients received an order for neuroleptics and only 16% had simultaneous orders for both definite anticholinergic and anti-dementia drugs. Conclusion: The tools of ‘implementation science’ can be utilized to translate a health care delivery model developed in the research laboratory to a practical, operational, health care delivery program.

Practical clinical tool to monitor dementia symptoms: the HABC-Monitor.

Background Dementia care providers need a clinical assessment tool similar to the blood pressure cuff (sphygmomanometer) used by clinicians and patients for managing hypertension. A “blood pressure cuff ” for dementia would be an inexpensive, simple, user-friendly, easily standardized, sensitive to change, and widely available multidomain instrument for providers and informal caregivers to measure severity of dementia symptoms. The purpose of this study was to assess the reliability and validity of the Healthy Aging Brain Care Monitor (HABC-Monitor) for measuring and monitoring the severity of dementia symptoms through caregiver reports. Methods The first prototype of the HABC-Monitor was developed in collaboration with the Indianapolis Discovery Network for Dementia, which includes 200 members representing 20 disciplines from 20 local organizations, and an expert panel of 22 experts in dementia care and research. The HABC-Monitor has three patient symptom domains (cognitive, functional, behavioral/psychological) and a caregiver quality of life domain. Patients (n = 171) and their informal caregivers (n = 171) were consecutively approached and consented during, or by phone shortly following, a patient’s routine visit to their memory care provider. Results The HABC-Monitor demonstrated good internal consistency (0.73–0.92); construct validity indicated by correlations with the caregiver-reported Neuropsychiatric Inventory (NPI) total score and NPI caregiver distress score; sensitivity to three-month change compared with NPI “reliable change” groups; and known-groups validity, indicated by significant separation of Mini-Mental Status Examination severity groups and clinical diagnostic groups. Although not designed as a screening study, there was evidence for good operating characteristics, according to area under the receiver-operator curve with respect to gold standard clinical diagnoses, relative to Mini-Mental Status Examination or NPI. Conclusion The HABC-Monitor demonstrates good reliability and validity as a clinically practical multidimensional tool for monitoring symptoms of dementia through the informal caregiver.

New Workforce Development in Dementia Care: Screening for “Caring”: Preliminary Data

The United States has a significant shortage of trained geriatricians and of nurses, social workers, and paraprofessionals educated to care for elderly adults. As the aging population continues to grow, providing high‐quality care will require new models that better address the many needs of aging individuals and their caregivers, using cost‐effective strategies. Responding to this need, the Indiana University Center for Aging Research implementation scientists developed, tested, and are now scaling up a successful collaborative care coordination model for older adults with dementia, depression, or both: the Aging Brain Care program. This model now includes a newly created frontline care provider position, the Care Coordinator Assistant. The Care Coordinator Assistant works with individuals and caregivers to monitor biopsychosocial needs and deliver evidence‐based and individualized care protocols, with close supervision from the registered nurse Care Coordinator. Recognizing that current hiring practices for frontline providers were insufficient to screen for critical abilities expected in this new position, including the ability to express “caring” and empathy, a new screening process was created building on the Multiple Mini Interview (MMI) format. The Care Coordinator Assistant MMI comprised six stations, each created to simulate challenging scenarios that will be frequently encountered and to assess important candidate abilities. Overall, the six‐station MMI, with two to three items per station, provided factorially valid measures and good predictive ability. The process did not appear to be overly burdensome for candidates, and interviewers noted that it was helpful in discriminating between candidates.

Healthy Aging Brain Center Improved Care Coordination And Produced Net Savings

Over the past two decades the collaborative care model within primary care has proved to be effective in improving care quality, efficiency, and outcomes for older adults suffering from dementia and depression. In collaboration with community partners, scientists from Indiana University have implemented this model at the Healthy Aging Brain Center (HABC), a memory care clinic that is part of Eskenazi Health, an integrated safety-net health care system in Indianapolis, Indiana. The HABC generates an annual net cost savings of up to

The Aging Brain Care Medical Home: Preliminary Data

2,856 per patient, which adds up to millions of dollars for Eskenazi Healths patients. This article demonstrates the financial sustainability of the care processes implemented in the HABC, as well as the possibility that payers and providers could share savings from the use of the HABC model. If it were implemented nationwide, annual cost savings could be in the billions of dollars.

The Healthy Aging Brain Care (HABC) Monitor: validation of the Patient Self-Report Version of the clinical tool designed to measure and monitor cognitive, functional, and psychological health

The Aging Brain Care (ABC) Medical Home aims to improve the care, health outcomes, and medical costs of Medicare beneficiaries with dementia or depression across central Indiana. This population health management program, funded by the Centers for Medicare and Medicaid Services Innovation Center, expanded an existing collaborative dementia and depression care program to serve 1,650 older adults in a local safety‐net hospital system. During the first year, 20 full‐time clinical staff were hired, trained, and deployed to deliver a collaborative care intervention. In the first 18 months, an average of 13 visits was provided per person. Thirty percent of the sample had a diagnosis of dementia, and 77% had a diagnosis of depression. Sixty‐six percent of participants with high depression scores (Patient Health Questionnaire‐9 score ≥14) had at least a 50% reduction in their depressive symptoms. Fifty‐one percent of caregivers of individuals with dementia had at least a 50% reduction in caregiver stress symptoms (measured by the Healthy Aging Brain Care Monitor‐Caregiver Version). After 18 months, the ABC Medical Home has demonstrated progress toward improving the health of older adults with dementia and depression. Scalable and practical models like this show initial promise for answering the challenges posed by the nations rapidly aging population.

Workforce development to provide person-centered care

Background Primary care providers need an inexpensive, simple, user-friendly, easily standardized, sensitive to change, and widely available multidomain instrument to measure the cognitive, functional, and psychological symptoms of patients suffering from multiple chronic conditions. We previously validated the Caregiver Report Version of the Healthy Aging Brain Care Monitor (HABC Monitor) for measuring and monitoring the severity of symptoms through caregiver reports. The purpose of this study was to assess the reliability and validity of the Patient Self-Report Version of the HABC Monitor (Self-Report HABC Monitor). Design Cross-sectional study. Setting Primary care clinics affiliated with a safety net urban health care system in Indianapolis, Indiana, USA. Subjects A total of 291 subjects aged ≥65 years with a mean age of 72.7 (standard deviation 6.2) years, 76% female, and 56% African Americans. Analysis Psychometric validity and reliability of the Self-Report HABC Monitor. Results Among 291 patients analyzed, the Self-Report HABC Monitor demonstrated excellent fit for the confirmatory factor analysis model (root mean square error of approximation =0.030, comparative fit index =0.974, weighted root mean square residual =0.837) and good internal consistency (0.78–0.92). Adequate convergent–divergent validity (differences between the Telephone Interview for Cognitive Status test-based cognitive function impairment versus nonimpairment groups) was demonstrated only when patients were removed from analysis if they had both cognitive function test impairment and suspiciously perfect self-report HABC Monitor cognitive floor scores of 0. Conclusion The Self-Report HABC Monitor demonstrates good reliability and validity as a clinically practical multidimensional tool for measuring symptoms. The tool can be used along with its caregiver version to provide useful feedback (via monitoring of symptoms) for modifying care plans. Determining the validity of HABC Monitor scores from patients who self-report a perfect cognitive score of 0 requires cognitive function test results (eg, Telephone Interview for Cognitive Status or Mini Mental State Examination) or Caregiver Report HABC Monitor scores or further clinical examination to rule out the possibility that the patient is denying or unaware of their cognitive symptoms.

Redesigning acute care for cognitively impaired older adults: Optimizing health care services

ABSTRACT Objectives: Describe the development of a competent workforce committed to providing patient-centered care to persons with dementia and/or depression and their caregivers; to report on qualitative analyses of our workforces case reports about their experiences; and to present lessons learned about developing and implementing a collaborative care community-based model using our new workforce that we call care coordinator assistants (CCAs). Method: Sixteen CCAs were recruited and trained in person-centered care, use of mobile office, electronic medical record system, community resources, and team member support. CCAs wrote case reports quarterly that were analyzed for patient-centered care themes. Results: Qualitative analysis of 73 cases using NVivo software identified six patient-centered care themes: (1) patient familiarity/understanding; (2) patient interest/engagement encouraged; (3) flexibility and continuity of care; (4) caregiver support/engagement; (5) effective utilization/integration of training; and (6) teamwork. Most frequently reported themes were patient familiarity – 91.8% of case reports included reference to patient familiarity, 67.1% included references to teamwork and 61.6% of case reports included the theme flexibility/continuity of care. CCAs made a mean number of 15.7 (SD = 15.6) visits, with most visits for coordination of care services, followed by home visits and phone visits to over 1200 patients in 12 months. Discussion: Person-centered care can be effectively implemented by well-trained CCAs in the community.

Agile Implementation: A Blueprint for Implementing Evidence-Based Healthcare Solutions: IU Agile Implementation Blueprint

Purpose of the study Cognitive impairment (CI) is one of several factors known to influence hospitalization, hospital length of stay, and rehospitalization among older adults. Redesigning care delivery systems sensitive to the influence of CI may reduce acute care utilization while improving care quality. To develop a foundation of fundamental needs for health care redesign, we conducted focus groups with inpatient and outpatient providers to identify barriers, facilitators, and suggestions for improvements in care delivery for patients with CI. Design and methods Focus group sessions were conducted with providers to identify their approach to caring for cognitively impaired hospitalized adults; obstacles and facilitators to providing this care; and suggestions for improving the care process. Using a thematic analysis, two reviewers analyzed these transcripts to develop codes and themes. Results Seven themes emerged from the focus group transcripts. These were: (1) reflections on serving the cognitively impaired population; (2) descriptions of perceived barriers to care; (3) strategies that improve or facilitate caring for hospitalized older adults; (4) the importance of fostering a hospital friendly to the needs of older adults; (5) the need for educating staff, patients, and caregivers; (6) the central role of good communication; and (7) steps needed to provide more effective care. Implications Providing effective acute care services to older adults with CI is an important challenge in health care reform. An understanding derived from the perspective of multiple professional disciplines is an important first step. Future research will build on this preliminary study in developing new acute care models for patients with CI.

The Indiana Aging Brain Care Project

To describe the essential components of an Agile Implementation (AI) process, which rapidly and effectively implements evidence‐based healthcare solutions, and present a case study demonstrating its utility.