Feature ArticleDevelopment and testing of the Dementia Symptom Management at Home (DSM-H) program: An interprofessional home health care intervention to improve the quality of life for persons with dementia and their caregivers
Introduction
Home health care (HHC) providers, including registered nurses, and physical and occupational therapists, play a major role in caring for older adults after discharge home from the hospital and may be essential in keeping readmission rates low. Currently, 22% of HHC patients return to the ER after discharge and 29% are readmitted.1 Over two thirds of HHC patients are over the age of 652 and approximately 36% have some form of cognitive impairment3 including dementia. This number is expected to increase significantly given the aging of the population and rise in life expectancy.4 There are currently no treatments available to prevent or cure Alzheimer's disease and related disorders, and current symptomatic medications do not alter the disease trajectory. However, according to the Institute of Medicine, the number of providers trained to properly care for the older adult, including those with dementia and in the HHC setting is inadequate.5
Furthermore, the role of the interprofessional HHC team in treating persons living with dementia (PLWD) has not been clearly defined, despite the potential to identify and significantly improve the quality of life of both the PLWD and the caregiver. Dementia care can best be provided over time by an interprofessional team, defined as ‘a partnership between a team of health providers and a client in a participatory collaborative and coordinated approach to shared decision making around health and social issues’.6 Each discipline provides a distinct and complimentary set of skills to the team.7 The registered nurse is an expert in therapeutic communication and coping strategies, as well as caregiver education and provision of pharmacologic and non-pharmacologic interventions. The occupational therapist focuses on preserving functional capacity and determining the types of compensatory strategies, assistive devices and environmental modifications that are appropriate. The physical therapist focuses on mobility, reducing risk of injuries and falls, and maximizing completion of activities of daily living. Additional skilled disciplines that can be involved in HHC though are much less frequently used as part of the interprofessional team in this setting are the social worker and speech language pathologist.
Various successful interventions have been implemented in the community using non-pharmacologic strategies, performed by single disciplines such as nurses,8, 9 occupational therapists,10 and physical therapists11 as well as by interprofessional teams.12, 13, 14 However these interventions have often been created through research projects and not scaled up and integrated into existing models of care, especially those with interprofessional HHC teams.
Moreover, limited research has been performed in how to best implement evidence-based programs in HHC.15 Given that clinicians in HHC work in the community and may spend limited time at a home office,16 there are different challenges with both training of a workforce with members from different disciplines, and conducting an interprofessional education intervention compared to institutional settings such as hospitals and nursing homes.17, 18 Similarly, in-person training requires clinicians in HHC to leave the field and therefore productivity can be effected at a greater level than in institutional settings where they may have to leave a patient assignment and receive coverage but do not have to travel far from their practice setting. The authors have previously tested an online educational intervention in HHC on geriatric pain and depression, finding that it is feasible to implement online educational interventions in this setting.19 However, without additional resources such as protocols, care plans, sustained mentorship and quality improvement initiatives, there is limited potential for long-term efficacy.20, 21
The Dementia Symptom Management at Home (DSM-H) Program was designed to provide a multi-modal behavioral intervention that includes education, mentorship, and workflow changes to an interprofessional team with the intent of improving outcomes for PLWD and their caregivers. The DSM-H provides a structured way for HHC professionals to assess and manage pain and neuropsychiatric symptoms (NPS) such as agitation, aggression and psychosis in PLWD and decrease burden, stress and burnout in caregivers of PLWD. The DSM-H was developed primarily for the HHC interprofessional team of registered nurses, physical therapists, and occupational therapists, as they are the largest provider groups in HHC and provide complimentary but different care to PLWD utilizing different bases of knowledge and expertise.7
The aim of this study was to test the ability of the DSM-H Program to improve the knowledge, confidence, and attitudes of HHC registered nurses, physical therapists, and occupational therapists in assessing and managing pain, depression, and other NPS in PLWD. This study also sought to examine if this is a feasible resource to be used by interprofessional teams as we explore ways to improve the outcomes in PLWD and their caretakers.
Section snippets
Development of the DSM-H
The DSM-H was created by combining complementary elements of two interprofessional educational and training programs developed and validated by one of the authors (JEG),22, 23 the Nurses Improving Care for Healthsystems Elderly program24 developed by the Hartford Institute for Geriatric Nursing at NYU, the NIA/NINR developed and VA implemented Resources for Enhancing Alzheimer's Caregiver Health (REACH) program,25 and the Care of Persons with Dementia in their Environments (COPE) intervention
Results
Overall, all 191 individuals who completed consent took the initial survey (92.3% of eligible clinicians) and began the online training modules. Of those, while all 191 completed the training modules, only 43.5% completed post-test. Characteristics of completers and non-completers can be found in Table 1. There were no significant differences in general demographic factors, however those who completed on average had more overall training in geriatrics, and occupational therapist completers on
Discussion
While there has been a significant increase in the number of evidence-based geriatric care practices developed through rigorous science in the community based setting over the past 10 years, unlike in acute care where models of dissemination such as the NICHE program24 have been developed, no similar vehicle has been developed for community based care. This is similar to other fields of health, such as mental health care where it has been cited as a major gap in improving care.40 Those programs
Conclusion
This study, as an initial assessment of the interprofessional DSM-H program, showed varying improvements in the knowledge, confidence and attitudes in caring for PLWD amongst registered nurses, and physical and occupational therapists in HHC. It was implementable with limited internal resources at the agency, and was found by the clinicians to be applicable to their work and worthwhile. There is a significant need within HHC agencies to improve the care provided to PLWD, a fast growing segment
Acknowledgment
The authors would like to thank the National Palliative Care Research Center for its generous funding of this study.
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2020, Journal of Pain and Symptom ManagementCitation Excerpt :Aliviado dementia symptom management program was shown to be effective when used in a home health setting. Among 209 clinicians, significant improvements were found in knowledge, attitudes, and care confidence in treating PWD, varying by specialty.21 Therefore, Aliviado was adapted to a hospice setting with modifications to address key topic areas that are important to PWD in their final months of life.