COACH: Caring for Older Adults and Caregivers at Home

Abstract

Dementia is a major cause of disability and dependency in older adults and it has a physical, psychological, social, and economic impact on the affected individual as well as their caregivers. Most Americans with dementia receive care from their family members, and friends2. Care giving is associated with an increased level of psychological distress and lower subjective well-being and physical health2; caregiver support groups have been found to reduce angry and depressive feelings, improve caregiver's skills, maintain favorable health behaviors and quality of life, and increase social support and satisfaction for caregivers3. There is often a strong preference to keep the affected individual at home for as long as possible; however, significant behavioral challenges and caregiver strain lead to placement in a long-term care facility4. COACH is an innovative, longitudinal, home-based dementia care program serving veterans with dementia and their caregivers. The program originated as a clinical demonstration project by the Geriatric, Research, Education and Clinical Center at the Durham VA Health Care System (DVAHCS) in 2010. It became a fully established, permanent program in 2012 and expanded to rural Eastern North Carolina in 2014. COACH is designed to improve quality of life for veterans with dementia and their caregivers, with the goal of helping veterans remain at home for as long as possible. The criteria for COACH include veterans enrolled in VAHCS who are 65 or more years of age with moderate to severe cognitive impairment and who have a live-in caregiver. Enrolled veterans cannot be in another home-based program and must live within 50 miles from the COACH team's home clinic. The process begins with a consult to the COACH program from any health care provider. Once the veteran and their care giver are screened and found eligible, a LCSW and a RN conduct a comprehensive assessment. This includes psychosocial assessment; home safety assessment; evaluation of patient's cognitive and functional abilities; evaluation of patient's behaviors; medication review; and evaluation of care giver stress, knowledge of dementia, coping abilities, screening for depression and family resources. RN and LCSW consult with an interdisciplinary team of a geriatrician, a geriatric psychiatrist, and a geriatric pharmacist weekly to develop a comprehensive treatment plan integrating best evidence-based practices. After the initial assessment, LCSW and RN conduct follow ups via home visits or video and telephone contact at one, three, and six months. Home visits continue every six months with quarterly follow-ups via video or telephone, and additional ad-hoc home visits as recommended by the interdisciplinary team or needed by the caregiver. The team provides ongoing support and education to caregivers in five major areas of care. 1. Behavioral symptoms management: focuses on non-pharmacological approaches like communication skills, reminiscence and validation techniques, behavioral activation 2. Safety: addresses any safety hazards that may affect the veteran like driving or falls. 3. Advance care planning: offers anticipatory guidance and education on advance directives and end of life care preferences. 4. Caregiver burden: offers ongoing support to caregivers, emphasizes self-care. 5. Dementia related medical concerns: Offers pharmacological recommendations for safety, appropriateness, and compliance; guidance on strategies to maintain functioning, assistance with activities of daily living, and cover needs for durable medical equipment in the home. To augment the educational interventions, the program offers weekly caregiver support groups and monthly educational series talks on dementia. In the last in the last ten years, the program has served nearly 1,200 veterans, with about 100 new veterans enrolled each year. It has demonstrated ability to improve dementia care at home, delay long-term care facility placement6, reduce caregiver burden, and improve safety at home5. COACH exceeds all national dementia performance measures5.