Community Dementia Care and the Chronic Care Model
End-Stage Dementia Evaluation Proposal
Health Promotion Plan for Community End-Stage Dementia Care: The Chronic Care Model
Health Promotion Plan for Community End-Stage Dementia Care: The Chronic Care Model.
In 2013 an estimated 5.0 million Americans over the age of 65 suffered from Alzheimer's disease (Alzheimer's Association, 2013). Although the U.S. Centers for Disease Control and Prevention (CDC) considers dementia/Alzheimer's to be the fifth leading cause of death among adults 65-years of age or older, careful examination of Medicare claims data revealed that dementia is probably right behind cardiovascular disease as the second leading cause of death for this age group (Tinetti et al., 2012). Most of these patients would prefer to die at home, not only because of comfort concerns, but due to the higher quality of care that tends to be provided by informal and paid caregivers in this setting (reviewed by Teno et al., 2013). Unfortunately, nearly half (42.2%) of all dementia patients receiving Medicare coverage died in a hospice setting in 2009, compared to only 21.6% in 2000 (Teno et al., 2013). This may be good news for policymakers interested in increasing the use of hospice care, but not patients preferring to die in their own homes surrounded by loved ones. In addition to the increased reliance on hospice care, ICU admissions during the last 30 days of life increased during the same period. Improving the quality of the home-based palliative care experience may be one way to reverse this trend. Accordingly, a health promotion plan advocating the benefits of the Chronic Care Model (CCM) for home-based dementia care has been developed. What follows is a description of the intervention and the proposed outcome measures that will be used to evaluate the efficacy, efficiency, and quality of the intervention.
Intervention
The efficacy of CCM as an intervention for increasing the quality of home-based palliative care is currently being investigated by researchers (Brodaty & Donkin, 2009). The CCM has six core elements: (1) explicit protocols and policies, (2) emphasis on patient-centered care, (3) comprehensive services, (4) systematic attention to patient information and behavioral needs, (5) integrated multidisciplinary care, and (6) information systems to support clinical objectives. Preliminary research findings for a small, randomized Ohio sample (N = 80) provided trend data that supported the utility of CCM for reducing the number of unscheduled visits to hospitals and admissions to nursing homes (Radwany et al., 2013). A similar study, also with a small, randomized sample (N = 125), was completed in Finland, which revealed significantly lower rates of institutional care after 1.6 years and reduced healthcare spending (p = .03) (Eloniemi-Sulkava et al., 2009). What both studies reveal is that CCM can be implemented successfully and without substantially increasing overall healthcare spending. For these reasons, a health promotion plan for home-based dementia care has been proposed.
Efficacy Evaluation
Researchers have shown that individual elements of the CCM significantly delayed and/or prevented the use of institutional care during the last days of life (reviewed by Eloniemi-Sulkava et al., 2009). The CCM intervention implemented in Ohio incorporated a care manager who orchestrated healthcare services for both the patient and family members within a provider network (Radwany et al., 2013). This network consisted of the care manager, hospital-based geriatricians, primary care providers, and health care facilities. One of the expected benefits of the care network, for example, is seamless transitions between care settings. Another benefit would be a patient- and family-centered care orientation, such that the physical, psychological, and spiritual needs of the patient and family caregivers are addressed. The evaluation outcome measures for intervention efficacy should therefore include methods and instruments that can quantify how effective care transitions are being made and whether the quality of life for patients and family caregivers is improved compared to standard care.
Eloniemi-Sulkava and colleagues (2009) reviewed the concerns of family caregivers when caring for dementia patients and among the most common were patient physical disability and the behavioral and psychological symptoms associated with dementia (BPSD). An effective intervention for home care of dementia patients would therefore need to quantify activities of daily living (ADL) and instrumental activities of daily living (IADL) (Radwany et al., 2013). In addition, the behavioral and psychological symptoms due to dementia should be followed during the study period using a clinical instrument (Eloniemi-Sulkava et al., 2009).
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