EFFECTIVENESS OF A COLLABORATIVE CONTINUUM OF CARE MODEL FOR PATIENTS AND FAMILIES WITH DEMENTIA

Abstract

Patients, families, and providers struggle with the complexities of Alzheimer’s disease and related dementias as families report poor understanding and poor support for care planning. A quality improvement model was established at Stanford Health Care in 2008 to follow patients and families through the continuum. The model has since been strengthened with collaborations from Stanford’s Center for Memory Disorders and the Stanford NIH Alzheimer’s Disease Research Center. This poster outlines the results of a survey from caregivers receiving transitional care coordination and home visits. Survey revealed effectiveness of the program. The importance of integration (rather than fragmentation) of services and providers was stressed, along with knowing there was a number to call for support through the continuum. Of the 50% of respondents who completed the surveys: nearly 100% of respondents felt that consultations, family meetings, referrals, guidance and support during transitions of care were ‘Very Helpful’; that information on coping and understanding complex behavior was ‘Very Helpful’; that the information provided improved the quality of life for the patient; that the caregiver understood the disease better; and that the program helped their family avoid future problems. Nearly 100% ‘Strongly Agreed’ that they felt comfortable requesting help from staff in the future and had an overall satisfaction with being “heard” as new problems arise. At a junction where a cure is still far away, all efforts to support families and improve quality of life are strongly welcomed by families, most of whom have little or no preparation for a caregiving role.