Interprofessional care of patients with advanced dementia during critical transitions

Abstract

As dementia progresses, individuals and their caregivers experience a prolonged course of disability, frequently characterized by an increase in neuropsychiatric symptoms, acute medical events, and need for higher levels of care. In addition to the challenges caused by disease progression, transitions between levels of care contribute to distress for a number of reasons, including greater difficulty on the patient's part in comprehending what is happening and why, unfamiliar settings and people, and unnecessary or overly aggressive medical interventions. Successful long-term placement can be challenging, particularly for those with behavioral symptoms. Many of these patients end up requiring hospitalization, often leading to a "revolving door" cycle of failed placement attempts and rehospitalizations.Various models of care have been developed to address these issues. The Behavioral Recovery Outreach (BRO) Team, an interprofessional team providing inpatient care and assistance with community placement for patients with advanced dementia, represents one such model. This model of care originated at the Des Moines VA in 2012 and has expanded to other VA systems across the country with variations in implementation but an overall core philosophy of holistic dementia care. Non-pharmacologic interventions are first-line therapy for commonly encountered symptoms of emotional distress, agitation, and aggression. Some of these include tailoring the environment to a Veteran's preferences, creating space for safe movement or music, or individualizing bedside cares to reduce distress. BRO Teams have been shown to reduce distressing behaviors associated with dementia and increase success of long-term placement for these patients.The BRO Team at the Minneapolis VA was created in 2016. The team provides subacute behavioral management in the VA's Community Living Center (CLC), after Veterans have been hospitalized on acute med-surg units for behavioral symptoms related to dementia. The team then supports Veterans through their transitions to long-term care settings.This presentation will provide an introduction to BRO Teams and describe the efficacy of the BRO Team and unit at the Minneapolis VA. Additionally, we will discuss how the BRO Team model of care fits into dementia services in the larger health care system. We will review data on various paths that patients with dementia take through the many specialized services and levels of care. In doing so, we will reflect on issues related to disparities in health care, and key points in a patient's and family's journey that may be particularly beneficial in terms of reducing stress, planning effectively for the future, and maintaining a positive quality of life. Our discussion will conclude with a literature review on the implementation of interprofessional teams for managing dementia-related behavioral challenges across different models of care.