Key components in models of community-based interventions coordinating care in dementia: a mixed studies systematic review protocol

Transcending inequities in dementia care in Black communities: Lessons from the maximizing independence at home care coordination program

Purpose

We examine care partners’ experience of the Maximizing Independence at Home (MIND) intervention, a multicomponent, home-based dementia care coordination program designed to provide high quality, wholistic care coordination for people and families living with dementia. The goal of the study was to understand 1. the unique dementia-related needs of Black care partners and barriers and challenges to caregiving experienced within the Black community, 2. perceived benefits of the MIND program, and 3. ways to improve the program and make it more culturally responsive to the Black community.

Method

We conducted three focus groups totaling 20 care partners of people living with dementia; who participated in the MIND intervention (2014–2019); all Black/African American and English speaking. Verbatim transcriptions were independently analyzed line-by-line by two coders using inductive approaches.

Findings

Participants noted three overarching themes related to dementia care needs and challenges in the Black community: difficulty finding and accessing dementia information and relevant services and supports; familial conflict/lack of sibling and familial support; and lack of effective communication about dementia within Black Communities. Regarding MIND at home program benefits, four themes emerged: 1. perceived to help locate resources (formal and informal); 2. provided care partners an opportunity for socialization and interaction; 3. included comprehensive assessments and helpful linked information; and 4. resulted in a “much needed break for care partners.” Increased diversity of the MIND program personnel, greater clarity and consistency in MIND program promotion, and better communications were themes for how the program could be improved.

Conclusion

Care partners participating in the MIND program perceived common benefits in aspects related to care for the persons living with dementia as well as benefits to themselves, believed the program addressed important challenges and gaps in education, services, and social support, and could be enhanced in its delivery and cultural responsiveness.

Effects of case management intervention for people with dementia and their carers: A systematic review and meta-analysis of experimental studies

BACKGROUND

Case management has been developed and suggested as a method for improving the quality of dementia care by optimising care service and delivery using a feasible and cost-effective approach. However, the effects of case management for improving dementia care remain inconclusive.

AIM

To analyse the efficacy of case management interventions for people with dementia and their carers.

DESIGN

Systematic review and meta-analysis.

METHODS

This study conducted a systematic review of the literature from January 1, 2002, to March 15, 2021, indexed in the following databases: Academic Search Complete, CINAHL, Cochrane Library, EMBASE, MEDLINE, PubMed, OVID, and Web of Science. Intervention studies examining patients with dementia and their carers published in the English language were included. The methodological quality of included studies was evaluated using the PEDro scale. The meta-analysis was performed using a random-effects model to calculate the pooled standardised mean difference (SMD) of case management intervention outcomes for both people with dementia (cognitive function, neuropsychiatric symptoms, and quality of life) and their carers (carer burden). Stata 16.0 was used for statistical analysis.

RESULTS

A total of eight studies met the eligibility criteria for this study. The results of the quantitative analysis, ranging from 6 to 18 months, showed no significant effect on cognitive function, quality of life over 12 months and longer, and carer burden over time between groups with and without intervention. However, significant improvements were observed for neuropsychiatric symptoms over 12 months and longer and quality of life at six months in the case management group.

CONCLUSION

Case management appears to have the potential to improve the health outcomes among people with dementia. However, these conclusions are limited due to the lack of conducted studies. Future work examining intervention outcomes remains necessary to explore the effects of interventions on the mental and physical wellbeing of carers.

What works in managing complex conditions in older people in primary and community care? A state-of-the-art review

The number of older people living with complex health conditions is increasing, with the majority of these managed in primary and community settings. Many models of care have been developed to support them, however, there is mixed evidence on their value and they include multiple overlapping components. We aimed to synthesise the evidence to learn what works for managing complex conditions in older people in primary and community care. We carried out a state-of-the-art review of systematic reviews. We searched three databases (January 2009 to July 2019) for models of primary and community care for long-term conditions, frailty, multimorbidity and complex neurological conditions common to older people such as dementia. We narratively synthesised review findings to summarise the evidence for each model type and identify components which influenced effectiveness. Out of 2,129 unique titles and abstracts, 178 full texts were reviewed and 54 systematic reviews were included. We found that the models of care were more likely to improve depressive symptoms and mental health outcomes than physical health or service use outcomes. Interventions including self-management, patient education, assessment with follow-up care procedures, and structured care processes or pathways had greater evidence of effectiveness. The level of healthcare service integration appeared to be more important than inclusion of specific professional types within a team. However, more experienced and qualified nurses were associated with better outcomes. These conclusions are limited by the overlap between reviews, reliance on vote counting within some included reviews and the quality of study reports. In conclusion, primary and community care interventions for complex conditions in older people should include: (a) clear intervention targets; (b) explicit theoretical underpinnings; and (c) elements of self-management and patient education, structured collaboration between healthcare professionals and professional support. Further work needs to determine the optimal intensity, length, team composition and role of technology in interventions.

Consensus statement of the international summit on intellectual disability and Dementia related to post-diagnostic support. Aging Ment Health 2018;22:1406-1415. [PMID: 28880125 DOI: 10.1080/13607863.2017.1373065]

OBJECTIVES

Post diagnostic support (PDS) has varied definitions within mainstream dementia services and different health and social care organizations, encompassing a range of supports that are offered to adults once diagnosed with dementia until death.

METHOD

An international summit on intellectual disability and dementia held in Glasgow, Scotland in 2016 identified how PDS applies to adults with an intellectual disability and dementia. The Summit proposed a model that encompassed seven focal areas: post-diagnostic counseling; psychological and medical surveillance; periodic reviews and adjustments to the dementia care plan; early identification of behaviour and psychological symptoms; reviews of care practices and supports for advanced dementia and end of life; supports to carers/ support staff; and evaluation of quality of life. It also explored current practices in providing PDS in intellectual disability services.

RESULTS

The Summit concluded that although there is limited research evidence for pharmacological or non-pharmacological interventions for people with intellectual disability and dementia, viable resources and guidelines describe practical approaches drawn from clinical practice. Post diagnostic support is essential, and the model components in place for the general population, and proposed here for use within the intellectual disability field, need to be individualized and adapted to the person's needs as dementia progresses.

CONCLUSIONS

Recommendations for future research include examining the prevalence and nature of behavioral and psychological symptoms (BPSD) in adults with an intellectual disability who develop dementia, the effectiveness of different non-pharmacological interventions, the interaction between pharmacological and non-pharmacological interventions, and the utility of different models of support.

Stakeholders perspectives on the key components of community-based interventions coordinating care in dementia: a qualitative systematic review

BACKGROUND

Interventions aiming to coordinate services for the community-based dementia population vary in components, organisation and implementation. In this review we aimed to investigate the views of stakeholders on the key components of community-based interventions coordinating care in dementia.

METHODS

We searched four databases from inception to June 2015; Medline, The Cochrane Library, EMBASE and PsycINFO, this was aided by a search of four grey literature databases, and backward and forward citation tracking of included papers. Title and abstract screening was followed by a full text screen by two independent reviewers, and quality was assessed using the CASP appraisal tool. We then conducted thematic synthesis on extracted data.

RESULTS

A total of seven papers from five independent studies were included in the review, and encompassed the views of over 100 participants from three countries. Through thematic synthesis we identified 32 initial codes that were grouped into 5 second-order themes: (1) case manager had four associated codes and described preferences for the case manager personal and professional attributes, including a sound knowledge in dementia and availability of local services; (2) communication had five associated codes and emphasized the importance stakeholders placed on multichannel communication with service users, as well as between multidisciplinary teams and across organisations; (3) intervention had 11 associated codes which focused primarily on the practicalities of implementation such as the contact type and frequency between case managers and service users, and the importance of case manager training and service evaluation; (4) resources had five associated codes which outlined stakeholder views on the required resources for coordinating interventions and potential overlap with existing resources, as well as arising issues when available resources do not meet those required for successful implementation; and (5) support had seven associated codes that reflect the importance that was placed on the support network around the case manager and the investment of professionals involved directly in care as well as the wider professional network.

CONCLUSION

The synthesis of relevant qualitative studies has shown how various stakeholder groups considered dementia care coordination interventions to be acceptable, useful and appropriate for dementia care, and have clear preferences for components, implementation methods and settings of these interventions. By incorporating stakeholders' perspectives and preferences when planning and developing coordinating interventions we may increase the likelihood of successful implementation and patient benefits.

The effectiveness of community-based coordinating interventions in dementia care: a meta-analysis and subgroup analysis of intervention components

Background

Interventions aiming to coordinate services for the community-based dementia population vary in components, organisation and implementation. In this review we aimed to evaluate the effectiveness of community-based care coordinating interventions on health outcomes and investigate whether specific components of interventions influence their effects.

Methods

We searched four databases from inception to April 2017: Medline, The Cochrane Library, EMBASE and PsycINFO. This was aided by a search of four grey literature databases, and backward and forward citation tracking of included papers. Title and abstract screening was followed by a full text screen by two independent reviewers, and quality was assessed using the CASP appraisal tool. We then conducted meta-analyses and subgroup analyses.

Results

A total of 14 randomised controlled trials (RCTs) involving 10,372 participants were included in the review. Altogether we carried out 12 meta-analyses and 19 subgroup analyses. Meta-analyses found coordinating interventions showed a statistically significant improvement in both patient behaviour measured using the Neuropsychiatric Inventory (NPI) (mean difference (MD) = −9.5; 95% confidence interval (CI): −18.1 to −1.0; p = 0.03; number of studies (n) = 4; I² = 88%) and caregiver burden (standardised mean difference (SMD) = −0.54; 95% CI: -1.01 to −0.07; p = 0.02; n = 5, I² = 92%) compared to the control group. Subgroup analyses found interventions using a case manager with a nursing background showed a greater positive effect on caregiver quality of life than those that used case managers from other professional backgrounds (SMD = 0.94 versus 0.03, respectively; p < 0.001). Interventions that did not provide supervision for the case managers showed greater effectiveness for reducing the percentage of patients that are institutionalised compared to those that provided supervision (odds ratio (OR) = 0.27 versus 0.96 respectively; p = 0.02). There was little evidence of effects on other outcomes, or that other intervention components modify the intervention effects.

Conclusion

Results show that coordinating interventions in dementia care has a positive impact on some outcomes, namely patient behaviour and caregiver burden, but the evidence is inconsistent and results were not strong enough to draw definitive conclusions on general effectiveness. With the rising prevalence of dementia, effective complex interventions will be necessary to provide high quality and effective care for patients, and facilitate collaboration of health, social and third sector services.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2677-2) contains supplementary material, which is available to authorized users.

A qualitative study on barriers to achieving high-quality, community-based integrated dementia care

Introduction: High-quality, community-based dementia care requires a comprehensive, holistic approach. This study aimed to identify the barriers to achieving efficient cooperation and coordination among medical professionals, care managers, and medical social workers, and to improve the management model of community-based, integrated dementia care.

Methods: We collected qualitative data through three focus group discussions at JA Konan Kosei Hospital. Thirteen participants (four directors of nursing service departments, three chief nurses, four medical social workers, and two care managers) were recruited for the discussions. The data were analyzed using an inductive, multi-step approach referred to as the qualitative content analysis.

Results: Nine themes arose as follows: little attention given to patient wishes, lack of time and space to provide high-quality care, disturbing hospital environment, poor compensation for staff members, refusing to visit outpatient clinics, declined admission, daily life support by family members and caregivers, dementia care team, and community bonding.

Conclusion: The participants wanted to launch a dementia care team in their hospital to improve the care environment and the quality of dementia-specific care. The study also suggested that advance care planning could be systematically implemented in clinical practice as a way to honor the decisions made by dementia patients.