The associations between unmet needs with protective factors, risk factors and outcomes among care partners of community-dwelling persons living with dementia

OBJECTIVES

Describe the prevalence and types of unmet needs among community-dwelling dementia care partners (CPs) and determine associations between unmet needs with protective factors, risk factors and outcomes.

METHOD

A cross-sectional analysis of 638 racially and cognitively diverse community-dwelling persons living with dementia (PLWD) and their CPs participating in a comprehensive in-home assessment of dementia-related needs. Unmet CP needs (19 items, 6 domains) were rated by a clinician using the Johns Hopkins Dementia Care Needs Assessment (JHDCNA). Multivariate linear regression models were used to examine associations between total percent unmet CP needs with demographic, protective and risk factors.

RESULTS

Nearly all CPs had at least one unmet need (99.53%), with a mean of 5.7 (±2.6). The most common domains with ≥1 unmet need were memory disorder education, care skills and knowledge of resources (98%), legal issues/concerns (73.8%), CP mental health (44.6%) and access to informal support (42.7%). Adjusted multivariate models suggest the strongest consistent predictive factors relate to informal emotional support, CP physical health, use or difficulty getting formal services/supports (both for CPs and PLWD), and CP time spent with PLWD. Greater levels of unmet needs were associated with worse PLWD outcomes and CP outcomes, after adjusting for demographics.

CONCLUSIONS

CPs have high rates of diverse, but modifiable unmet needs. Data suggest optimal approaches to dementia care should take a family-centered home-based approach that includes routine CP needs assessment, offer targeted interventions that include both traditional medical supports as well as strategies to increase and leverage informal social networks, and ones that can bridge and coordinate medical with non-medical supports. These findings can be used to inform new approaches to support CPs, improve PLWD and CP outcomes, and target groups most at risk for inequities.

Reasons for Hospitalization while Receiving Dementia Care Coordination through Maximizing Independence at Home

OBJECTIVES

Persons living with dementia (PLWD), particularly those with higher levels of functional impairment, are at increased risk of hospitalization and higher hospital-associated health care costs. Our objective was to provide a nuanced description of reasons for hospitalizations over a 12-month period among community-living persons with dementia taking part in a dementia care coordination study using caregiver-reported data and to describe how reasons varied by disease stage.

DESIGN

Retrospective descriptive analysis of pooled data from 2 concurrent studies of PLWD receiving the MIND at Home dementia care coordination program.

SETTING AND PARTICIPANTS

Four hundred ninety-four community-dwelling PLWD with a family caregiver in the Greater Baltimore and Central Maryland region, 2015‒2019.

METHODS

PLWD sociodemographic, clinical, functional, cognitive, and behavioral characteristics were assessed during an in-home baseline visit. Caregiver-reported hospitalizations and primary reasons for events were recorded every 4.5 months by research staff and by memory care coordinators during program delivery for a 12-month period. Hospitalization event data were subsequently reviewed, reconciled, and coded by a trained investigator.

RESULTS

One hundred seventy PLWD (34.4%) had at least 1 hospitalization within 12 months of enrollment, with 316 separate events. The most common primary reason for hospitalization according to caregivers was infection (22.4%), falls (16.5%), and cardiovascular/pulmonary (12.4%). Top reasons for hospitalization were falls among persons with mild and moderate functional impairment (17.7% and 21.9% respectively) and infection among PLWD with severe impairment (30.3%).

CONCLUSIONS AND IMPLICATIONS

Infections and falls were the most common caregiver-reported reasons for hospitalization in PLWD receiving dementia care coordination. Reasons for hospitalization varied based on severity of functional impairment. Greater understanding of reasons for hospitalization among PLWD receiving dementia care management interventions, from multiple important perspectives, may help programs more effectively address and prevent hospitalization.

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.

Recruitment of a diverse research cohort in a large metropolitan area for dementia intervention studies

The human and financial costs of dementia care are growing exponentially. Over five and a half million older Americans are estimated to be living with Alzheimer's disease and related dementia (ADRD). By 2050, this is expected to increase to over 13 million, and persons of color are at the highest risk. Considerable funds have been committed to research to prevent, treat, and care for persons at risk for ADRD. However, enrollment of research participants, particularly those coming from diverse backgrounds, is a perennial challenge and has serious implications. This paper quantitatively details the results of a community-based multi-modal outreach effort to recruit a racially diverse sample for non-pharmacological dementia intervention, including referral and participant sources and yield, total recruitment costs and cost per enrolled dyad, and a qualitative description of lessons learned, with particular attention to the recruitment of Black participants. The largest number of referrals and referrals converting to study participants, for both Black and White persons, were from a Maryland Department of Health mailing to Medicaid recipients. There was an important difference in the most effective strategies, proportionally, for white and Black participants. The MDH mailing had the highest yield for our Black referrals and participants, while professional referrals had the highest yield for white referrals and participants. The total estimated cost of recruitment was $101,058, or $156.19 per enrolled dyad. Ultimately 646 persons with dementia and care partner dyads were enrolled, 323 (50%) of whom were Black.

Staff Perspectives on Lessons Learned From an Interdisciplinary Memory Care Coordination Program

MIND at Home is a home-based care coordination program for persons living with dementia (PLWD) and their informal care partners (CP). Assessments, care planning and coordination is delivered by trained non-clinical Memory Care Coordinators (MCCs), working together on an interdisciplinary team with nurses and geriatric psychiatrists. We report qualitative results from program staff (two nurses and eight MCCs) who implemented the program in the context of two clinical trials. Care team respondents answered open-ended questions covering 5 domains pertaining to: helpful skillsets; positive and challenging factors aspects of care coordination; barriers to care coordination for clients; and improvements suggestions/resources to strengthen the program. Compassion, finding common ground, listening, organization, and time management were reported as critical skills. Staff enjoyed team collaboration, being in and learning about the community, increasing CP confidence and mastery when caring for a PLWD. Reported challenges included documentation in EHR, accessing/navigating resources, driving long distances, unsafe neighborhoods, ambiguous assessment tools, and working with low engagement clients. Common barriers faced by clients (as reported by staff) were financial struggles/poverty, and lack of insurance coverage for needed services. Staff suggested several improvements: better communication strategies, integration with LTSS services and medical providers, 24-hour program hotline, continuous education for staff, simplified data collection and care delivery tracking process. This presentation on the experience of MIND at Home trained nurses and MCCs provides deep insight on how this and similar care coordination programs might be successfully implemented or strengthened.

Transcending Inequities in Dementia Care in Black Communities: Lessons From the MIND Care Coordination Program

Previous cognitive learning interventions have focused primarily on learning one or two novel real-world skills at a time, or utilizing computer-based programs to enhance specific cognitive skills (Ball et. al 2002; Park et. al, 2014). While these studies yielded immediate cognitive improvements in participants, the long-term benefits of continuing to learn several real-world skills in older adulthood is unclear. In the present two studies, the long-term (1-year post-intervention) benefits of a multi-skill learning intervention were investigated with older adult participants. Study 1 (a pilot sample) included 6 participants (67% female, M = 66.33 years, SD = 6.41, range = 58–74 years old) and Study 2 included 27 participants (67% female, M = 69.44 years, SD= 7.12, range = 58–86 years old). Following a three month intervention which entailed simultaneously learning at least three real-world skills, such as photography, drawing, and Spanish, participants’ cognitive abilities were assessed using four tasks (Flanker, Set-Shifting, Dot Counting, and N-Back), as well as RAVLT and Digit Span. Follow-up assessments were completed at three-, six-, and 12-month follow-ups after the interventions. Linear mixed-effects regression models revealed significant cognitive improvements across time points up to one year following the intervention compared to baseline assessments. These promising results support the idea that intense learning experiences may lead to considerable cognitive growth in older adulthood, as they do earlier in the lifespan.

Virtual Interdisciplinary Collaboration in Statewide Implementation of the MIND at Home Dementia Care Program

MIND at Home, a well-researched holistic, family-centered dementia care coordination program, provides collaborative support to community-dwelling persons living with dementia (PLWD) and their informal care partners (CP). Through comprehensive home-based assessment of 13 memory-care domains covering PLWD and CPs, individualized care plans are created, implemented, monitored, and revised over the course of the illness. Non-clinical Memory Care Coordinators (MCCs) working with an interdisciplinary team provide education and coaching to PLWD and their identified CP, and serve as a critical liaison and resource and between families, medical professional, and formal and informal community resources. This paper will describe a statewide pilot implementation of the program within a health plan across diverse sites in Texas and will present qualitative and quantitative descriptions of a key component of the program's effective translation to practice, the virtual collaborative case-based learning sessions. Health plan teams completed online interactive training modules and an intensive in-person case-based training with the Johns Hopkins team prior to program launch, and then engaged in weekly, hour-long virtual collaborative sessions that included health plan teams (site-based field teams, health plan clinical supervisory and specialty personnel [RNs, pharmacists, a geriatric psychiatrist, behavioral health specialists] and Johns Hopkins MIND program experts and geriatric psychiatrists. To date, the program has enrolled 350 health plan members, conducted 65 virtual collaborative sessions, and provided 423 CME/CEU units to team members. We will provide an overview of virtual collaborative session structure, participant contributions and discussion topics, case complexity, as well as didactic learning topics covered.

Telehealth Use in a Home-Based Dementia Care-Coordination Program

In the coming decades, greater numbers of people will either have Alzheimer’s Disease or a related dementia or will take care of a family member with dementia. The dementia syndromes are associated with increased risk of medical, social, and behavioral complications in both the person with dementia (PWD) and the caregiver (CG), many of which are preventable. These complications, and the dementia itself, can impede access to care and ultimately hasten residential care placement, which can be both undesirable and costly. A nearly universal unmet need in PWD/CG dyads is dementia-specific education. Therefore, it is vital we find ways to support and provide education to CG/PWD dyads to manage dementia in the community and home setting. MIND at Home is a dementia-care model developed and tested at Johns Hopkins University School of Medicine to minimize dementia complications and delay institutionalization by training non-clinical Memory Care Coordinators (MCCs) working under clinical supervision to support and guide PWD/CG dyads in the community. MCCs collaborate with CGs and PWDs in the community using an individualized care plan structured around the dyads’ specific dementia-related needs. This presentation will describe how the MIND at Home team used handheld tablets to connect MCCs to clinicians from participants’ homes, and will report on challenges encountered, strategies to address them, and participant and caregiver satisfaction with the telehealth experience.

Cost-Effective Care Coordination for People With Dementia at Home

Background and Objectives

People with dementia (PWD) represent some of the highest-need and highest-cost individuals living in the community. Maximizing Independence (MIND) at Home is a potentially cost-effective and scalable home-based dementia care coordination program that uses trained, nonclinical community workers as the primary contact between the PWD and their care partner, supported by a multidisciplinary clinical team with expertise in dementia care.

Research Design and Methods

Cost of care management services based on actual time spent by care management personnel over first 12 months of MIND at Home intervention was calculated for 342 MIND at Home recipients from Baltimore, Maryland and surrounding areas participating in a Centers for Medicare and Medicaid Services (CMS) funded Health Care Innovation Award demonstration project. Difference-in-differences analysis of claims-based Medicaid spending of 120 dually-eligible MIND at Home participants with their propensity score matched comparison group (n = 360).

Results

The average cost per enrollee per month was $110, or $1,320 per annum. Medicaid expenditures of dually-eligible participants grew 1.12 percentage points per quarter more slowly than that of the matched comparison group. Most savings came from slower growth in inpatient and long-term nursing home use. Net of the cost of the 5-year MIND at Home intervention, 5-year Medicaid savings are estimated at $7,052 per beneficiary, a 1.12-fold return on investment.

Discussion and Implications

Managed care plans with the flexibility to engage community health workers could benefit from a low-cost, high-touch intervention to meet the needs of enrollees with dementia. Limitations for using and reimbursing community health workers exist in Medicare fee-for-service, which CMS should address to maximize benefit for PWD.

MIND at Home-Streamlined: Study protocol for a randomized trial of home-based care coordination for persons with dementia and their caregivers

BACKGROUND

Dementia is associated with high health care costs, premature long-term care (LTC) placement, medical complications, reduced quality of life, and caregiver burden. Most health care providers and systems are not yet organized or equipped to provide comprehensive long-term care management for dementia, although a range of effective symptoms and supportive care approaches exist. The Maximizing Independence at Home-Streamlined (MIND-S) is a promising model of home-based dementia care coordination designed to efficiently improve person-centered outcomes, while reducing care costs. This report describes the rationale and design of an NIA-funded randomized controlled trial to test the impact of MIND-S on time to LTC placement, person with dementia outcomes (unmet needs, behavior, quality of life), family caregiver outcomes (unmet needs, burden), and cost offset at 18 (primary end point) and 24 months, compared to an augmented usual care group.

METHODS

This is a 24-month, parallel group, randomized trial evaluating MIND-S in a cohort of 304 community-living persons with dementia and their family caregivers in Maryland. MIND-S dyads receive 18 months of care coordination by an interdisciplinary team comprised of trained non-clinical community workers (e.g. Memory Care Coordinators), a registered nurse, and a geriatric psychiatrist. Intervention components include in-home dementia-related needs assessments; individualized care planning; implementation of standardized evidence-based care strategy protocols; and ongoing monitoring and reassessment. Outcomes are assessed by blinded evaluators at baseline, 4.5, 9, 13.5, 18, and 24 months.

DISCUSSION

Trial results will provide rigorous data to inform innovations in effective system-level approaches to dementia care.

Comprehensive home-based care coordination for vulnerable elders with dementia: Maximizing Independence at Home-Plus-Study protocol

INTRODUCTION

Despite availability of effective care strategies for dementia, most health care systems are not yet organized or equipped to provide comprehensive family-centered dementia care management. Maximizing Independence at Home-Plus is a promising new model of dementia care coordination being tested in the U.S. through a Health Care Innovation Award funded by the Centers for Medicare and Medicaid Services that may serve as a model to address these delivery gaps, improve outcomes, and lower costs. This report provides an overview of the Health Care Innovation Award aims, study design, and methodology.

METHODS

This is a prospective, quasi-experimental intervention study of 342 community-living Medicare-Medicaid dual eligibles and Medicare-only beneficiaries with dementia in Maryland. Primary analyses will assess the impact of Maximizing Independence at Home-Plus on risk of nursing home long-term care placement, hospitalization, and health care expenditures (Medicare, Medicaid) at 12, 18 (primary end point), and 24 months, compared to a propensity-matched comparison group.

DISCUSSION

The goals of the Maximizing Independence at Home-Plus model are to improve care coordination, ability to remain at home, and life quality for participants and caregivers, while reducing total costs of care for this vulnerable population. This Health Care Innovation Award project will provide timely information on the impact of Maximizing Independence at Home-Plus care coordination model on a variety of outcomes including effects on Medicaid and Medicare expenditures and service utilization. Participant characteristic data, cost savings, and program delivery costs will be analyzed to develop a risk-adjusted payment model to encourage sustainability and facilitate spread.

Home is where the future is: The BrightFocus Foundation consensus panel on dementia care

INTRODUCTION

A national consensus panel was convened to develop recommendations on future directions for home-based dementia care (HBDC).

METHODS

The panel summarized advantages and challenges of shifting to HBDC as the nexus of care and developed consensus-based recommendations.

RESULTS

The panel developed five core recommendations: (1) HBDC should be considered the nexus of new dementia models, from diagnosis to end of life in dementia; (2) new payment models are needed to support HBDC and reward integration of care; (3) a diverse new workforce that spans the care continuum should be prepared urgently; (4) new technologies to promote communication, monitoring/safety, and symptoms management must be tested, integrated, and deployed; and (5) targeted dissemination efforts for HBDC must be employed.

DISCUSSION

HBDC represents a promising paradigm shift to improve care for those living with dementia and their family caregivers: these recommendations provide a framework to chart a course forward for HBDC.

Behavioural health interventions in the Johns Hopkins Community Health Partnership: integrated care as a component of health systems transformation

Health systems in the USA have received a mandate to improve quality while reining in costs. Several opportunities have been created to stimulate this transformation. This paper describes the design, early implementation and lessons learned for the behavioural components of the John Hopkins Community Health Partnership (J-CHiP) programme. J-CHiP is designed to improve health outcomes and reduce the total healthcare costs of a group of high healthcare use patients who are insured by the government-funded health insurance programmes, Medicaid and Medicare. These patients have a disproportionately high prevalence of depression, other psychiatric conditions, and unhealthy behaviours that could be addressed with behavioural interventions. The J-CHiP behavioural intervention is based on integrated care models, which include embedding mental health professionals into primary sites. A four-session behaviour-based protocol was developed to motivate self-efficacy through illness management skills. In addition to staff embedded in primary care, the programme design includes expedited access to specialist psychiatric services as well as a community outreach component that addresses stigma. The progress and challenges involved with developing this programme over a relatively short period of time are discussed.

Presence of DNA of adeno-associated virus in subfertile couples, but no association with fertility factors

BACKGROUND

Based on previous reports suggesting a role of adeno-associated virus (AAV) in miscarriage, the prevalence of AAV DNA in genital tracts of male and female partners of subfertile couples was determined to assess a potential association of AAV infection with clinically relevant parameters of male and female fertility.

METHODS

A prospective study was performed in the outpatient infertility clinic of a university-based hospital. Semen samples and endocervical material obtained from 146 male and 134 female partners of asymptomatic subfertile couples were analyzed for the presence of AAV DNA (using nested PCR). Patients' medical histories and details of clinical examinations were recorded. Semen quality, including sperm functional capacity and the presence of antisperm antibodies (ASA) and seminal white blood cells (WBC), was assessed in aliquots of the same ejaculate. Detailed examinations of the cervical factor and other variables of female subfertility were performed. Both partners were screened for bacterial infection.

RESULTS

The presence of AAV DNA in semen was not significantly related to semen quality, including sperm functional capacity or local ASA, nor was it coupled to the presence of AAV in the endocervical material of female partners. The presence of AAV DNA was not associated with the presence of other micro-organisms of the lower genital tract or with seminal WBC in men. AAV DNA in endocervical material was not related to a reduced quality of cervical mucus or to other female infertility factors.

CONCLUSIONS

The presence of AAV DNA in semen samples or endocervical swabs showed no significant association with clinically relevant infertility factors. However, longitudinal studies may clarify previous suggestions of an influence of AAV infection on early pregnancy problems.

The formation of cluster elliptical galaxies as revealed by extensive star formation

The most massive galaxies in the present-day Universe are found to lie in the centres of rich clusters. They have old, coeval stellar populations suggesting that the bulk of their stars must have formed at early epochs in spectacular starbursts, which should be luminous phenomena when observed at submillimetre wavelengths. The most popular model of galaxy formation predicts that these galaxies form in proto-clusters at high-density peaks in the early Universe. Such peaks are indicated by massive high-redshift radio galaxies. Here we report deep submillimetre mapping of seven high-redshift radio galaxies and their environments. These data confirm not only the presence of spatially extended regions of massive star-formation activity in the radio galaxies themselves, but also in companion objects previously undetected at any wavelength. The prevalence, orientation, and inferred masses of these submillimetre companion galaxies suggest that we are witnessing the synchronous formation of the most luminous elliptical galaxies found today at the centres of rich clusters of galaxies.

Accuracy of medical records in hip fracture

OBJECTIVE

To determine the accuracy of diagnoses and procedure codes in medical records for hip fracture patients.

DESIGN

A validation sample of hip fracture medical records was used to compare the facesheet data with progress notes, operative reports, and discharge summaries for patients in a prospective study of functional recovery.

SETTING

Eight Baltimore hospitals with the highest volume of older hip fracture patients.

PATIENTS

Study subjects were 343 community-dwelling patients, 65 years of age and older, admitted to one of eight Baltimore hospitals between January 1990 and June 1991 with a diagnosis of hip fracture.

MAIN OUTCOME MEASURES

Facesheet diagnosis codes were compared with admitting notes, discharge summary, and/or progress notes. The abstracted surgical procedure was compared with postoperative radiographs.

RESULTS

Excess coding of diagnoses on the hospital facesheet was evident in 12% of charts. In 17% of charts, a complication identified in the chart was not coded on the facesheet. More complications with low severity were omitted. Agreement between the abstractor's procedure review and radiograph readings for arthroplasty was 84%. In 15% of patients, the abstractor coded total arthroplasty when hemiarthroplasty was done.

CONCLUSIONS

Discrepancy between the hospital facesheet and the medical record and between the abstracted surgical procedure and radiographs was found for hip fracture patients. This may make findings from health outcomes research relying on administrative databases uncertain and reimbursement inaccurate.

Psychological correlates of frequency and type of drug use among jail inmates

The comorbidity of drug abuse and various forms of psychopathology is pervasive and well documented. In particular, the incidence of depression, anxiety, and antisocial personality disorder is high among substance abusers relative to non-drug abusers. Offender populations have a high rate of substance abuse, and some studies suggest that the incidence of psychopathology may be even greater than in other drug using groups. In order to identify specific types of psychopathology as they relate to drug preferences and frequency of use among drug-using offenders, arrestees at the Baltimore City Detention Center were examined. During extensive interviews, drug-abusing arrestees provided information pertaining to their backgrounds, childhood histories, biological relatives, present behaviors, and criminal and drug histories. Additionally, several psychological inventories were administered to evaluate the presence of depression, anxiety, psychopathy, and impulsivity. Results indicate that the frequency with which subjects reported using specific drugs and drug of choice were significantly associated with particular measures of psychopathology. A composite measure of psychopathy was especially related to the frequency of alcohol, marijuana, and cocaine use. Subjects who reported using cocaine on a frequent basis scored high on measures of hostility and reported committing more property crimes, while violent crimes were more likely to be reported by subjects scoring high on the measure of psychopathy. Other noteworthy findings will be discussed along with the limitations of this study.

A novel insect defensin mediates the inducible antibacterial activity in larvae of the dragonfly Aeschna cyanea (Paleoptera, Odonata)

The injection of low doses of bacteria into the aquatic larvae of dragonflies (Aeschna cyanea, Odonata, Paleoptera) induces the appearance in their hemolymph of a potent antibacterial activity. We have isolated a 38-residue peptide from this hemolymph which is strongly active against Gram-positive bacteria and also shows activity against one of the Gram-negative bacteria which was tested. The peptide is a novel member of the insect defensin family of inducible antibacterial peptides, which had so far only been reported from the higher insect orders believed to have evolved 100 million years after the Paleoptera. Aeschna defensin is more potent than defensin from the dipteran Phormia, from which its structure differs in several interesting aspects, which are discussed in the paper.