Advisory Council January 2013 Meeting Presentation: VA Initiatives, Research, Support Program

ADVISORY COUNCIL ON ALZHEIMER'S RESEARCH, CARE, AND SERVICES

Monday, January 14, 2013

• VA Dementia Initiatives
• VA Dementia Research
• VA's Caregiver Support Program

VA Dementia Initiatives

Overview for Alzheimer's Research, Care, and Services
Advisory Council Meeting
January 14, 2013

U.S. Department of Veterans Affairs
Geriatrics & Extended Care Services (10P4G)
Susan Cooley, PhD, Chief, Dementia Initiatives

Outline

• Overview of VA dementia activities (Susan Cooley, PhD)
• VA dementia research (Pauline Sieverding, MPA, JD, PhD)
• VA caregiver support (Meg Kabat, LCSW-C, CCM)
• Questions & Answers

Guidance and Communication Infrastucture

• VHA Dementia Steering Committee (DSC) (recommendations)
• VHA Dementia Education and Training Committee (DET) (projects; curriculum development process)
• VISN and VAMC Dementia Committees (communication; local priorities)

Current Emphases

• Dementia Warning Signs (DWS) (improve recognition)
• Quality Indicator Dementia Workup (improve diagnosis)
• Patient Aligned Care Team (PACT) (recognition, diagnosis, care coordination)
• Non-institutional Extended Care Pilot Projects
• Challenging Behavior Staff Training

Dementia Warning Signs

• Dementia Warning Signs Workgroup (2011)
  • Quality improvement pilot project: 10 VA primary care sites; demonstrated feasibility/acceptability of DWS work processes and materials.
  • Toolkit: Staff training slides, posters, templated note in electronic health record to document warning signs and initiation of work-up.
  • Written guidance:
    • VHA NCP Clinician Fact Sheet: Detection of Dementia

Quality Indicator Dementia Workup -- FE18

• Frail Elderly (FE) Quality Indicator -- age 75+; external peer review chart extraction; sampled from selected clinics.
• FE18 Workup Prior to Dementia Diagnosis
  • Pilot measure began FY12; revised for FY13, continued pilot testing
  • History, Physical Exam, Laboratory Tests
  • Based on VHA Dementia Steering Committee recommendations for dementia workup

Patient Aligned Care Team/PACT

• PACT = Veteran-centric, team-based model of care; works collaboratively with Veteran/family; coordinates care across specialties, settings of care. (“Medical Home”)
  • Ongoing effort to integrate dementia care/care coordination needs into PACT team activities.
• Local efforts -- VISN/VAMC Dementia Committees, local champions work with PACT implementation.
• VA Central Office efforts -- DWS Toolkit, staff training; dementia diagnostic codes in PACT “Almanac” tool (allows grouping of patients by dx codes in medical record to facilitate patient cohort tracking).

Non-institutional Extended Care Pilot Projects

• Quality improvement pilot demonstration projects initiated 2010; broad range of non-institutional extended care topics.
• Projects with dementia focus:
  • 23 projects
  • Dementia care management, caregiver support, care transitions
• Some recently completed; summary evaluation/lessons learned pending.
• Some still ongoing.
• Good practices and lessons learned to be shared.

Challenging Behavior Staff Training

• 2008 educational conference; VISN Challenging Behavior Task Forces
• STAR-VA staff training in VA Community Living Centers -- pilot tested; expansion underway; dementia behavior management (adapted from L. Teri)
• Specific Behavioral Intervention staff training (approach, cueing) -- DVD; train-the-trainer sessions planned for FY13 for use in CLC, HBPC, inpatient psychiatry/medicine
• Dementia Communication Strategies (DVD) -- PACT training FY13
• Wandering (DVD, Satellite broadcast)
• Continuous meaningful activities (Satellite broadcast)

Centers of Excellence

• VA Geriatric Research, Education, and Clinical Centers (GRECCS) -- 19 GRECCs nationwide; 4 have major dementia focus (New England, Madison, Minneapolis, Puget Sound); others have minor focus/projects on dementia. www.va.gov/grecc
• VA Mental Illness Research, Education, and Clinical Centers (MIRECCs) --10 MIRECCs nationwide; 2 with major dementia focus (Seattle, Palo Alto). www.mirecc.va.gov

VA Dementia Research

Overview for Alzheimer's Research, Care, and Services
Advisory Council Meeting
January 14, 2013

U.S. Department of Veterans Affairs
Office of Research & Development
Pauline Sieverding, JD, PhD Scientific Program Manager, Long Term Care & Aging, Health Services Research

Veterans Health Administration

• VHA Operates the Nation’s Largest Integrated Health Care System
  • 6 million patients annually
  • 153 hospitals
  • 900 freestanding clinics
  • 135 nursing homes
  • 207 readjustment counseling centers
  • 60% of all practicing MDs have trained at VA hospitals

VHA Electronic Medical Record

Includes virtually all clinical information

Provides broad research value in aging medicine

Best Care Anywhere Screen Shots

VA Office of Research & Development

• Biomedical Laboratory Research & Development (BLR&D)
• Clinical Sciences Research & Development (CSR&D)
• Health Services Research & Development (HSR&D)
• Rehabilitation Research & Development (RR&D)

Major Research Areas of Alzheimer's Disease (AD) Supported by VA-ORD

• Biology & Pathophysiology of AD
  • Palo Alto VAMC –Exposing young mice to plasma from old mice decreases synaptic plasticity and impaired learning & memory. An identified blood chemokine, which increases in blood and CSF with aging in humans, decreased neurogenesis & impaired learning and memory when given to young mice. Blood-borne factors can play a critical role in neurodegenerative diseases. (Nature, Aug. 2011)
  • San Antonio VAMC. Exposure to herbicides have been linked to neurodegeneration. Exposing a transgenic animal model of AD to an herbicide caused cognitive impairment & amyloidogenesis and this was linked to mitochondrial damage disease. (Neurobiol. Aging, Feb. 2012)
• Diagnosis, Assessment & Disease Monitoring
  • Bronx VAMC-Discovery of neuropsychological markers of memory deficits/cognitive impairments & cerebrospinal biomarkers. Early clinical identification of cognitive impairments will allow expedited treatments & management. (Neurobiol. Aging, Dec. 2011)
• Drug Discovery, Pre-Clinical Drug Development, Clinical Interventions
  • Seattle VAMC- Studies of the regulation of the blood-brain barrier has lead to a demonstration that intravenously delivered antisense oligo-nucleotide, which is directed at the amyloid protein precursor (APP), completely reverses age-associated increase in APP & improved memory in a mouse model of AD (J. Alz. Dis. Feb.2012)
• Cooperative Studies Program (CSP) Trial for Alzheimer’s Disease
  • A randomized, clinical Trial of vitamin E And Memantine in AD (TEAM-AD).Memantine is a drug to treat symptoms of AD through blocking particular brain receptors.
  • Started 10/6/2005 Completed 9/1/2012
  • Over 600 subjects
  • Analysis of Data is on-going.
• Caregiver Support, Sociobehavioral Factors, & Delivery of Care
  • Nonpharmacologic Management of Challenging Behaviors in Veterans with Dementia --
    • Gainesville, FL VAMC -- A new project addresses the challenge of managing behavioral issues by testing the efficacy of a transformative patient-centric intervention designed to reduce the burden of behavioral problems in Veterans with dementia who live at home with family caregivers.
    • Systematic Evidence Review (2011) -- Looked at 28 systematic reviews and 25 primary articles in order to answer questions regarding non-pharmacological interventions for behavioral symptoms of dementia (VA-ESP Project 05-225).
  • Preventing Aggression in Veterans with Dementia --
    • Houston VAMC -- A new project is assessing whether a psychoeducational intervention: 1) decreases incidence of aggression, 2) decreases pain, 3) decreases caregiver burden and improves caregiver-patient relationship, and 4) decreases injuries, use of antipsychotic medication, and nursing home use.
  • Clinical Trial of a Home Safety Intervention for Alzheimer's Disease
    • Bedford VAMC -- found that a multimodal educational home safety tool-kit intervention was effective in improving caregiver competence to create a safer home environment, and decreased the risk and accidents to Veterans with dementia living in the community. The home safety tool-kit is now moving into the QUERI implementation phase.
  • Mobile Applications and Internet-based Approaches for Supporting Non-Professional Caregivers
    • Systematic Evidence Review on Mobile Applications and Internet-based Approaches for Supporting Non-Professional Caregivers (2012). This review examined the usage and effects of mobile tools on caregiver burden outcomes, patient outcomes, clinical process measures, and healthcare utilization.
• Long Term Care CREATE (Collaborative Research to Enhance Transformation and Excellence)
  • 3 coordinated, focused, multi-site research projects
    • INTERACT is a staff training and process control system that could be readily adopted if found to be successful in the VA CLC context.
    • The Discharge study provides useful information for GEC management and evaluates their efforts over the last several years to transform CLCs from long stay settings to post-acute programs responsive to Veterans’ needs, including how different Centers actually implement changes to meet this goal.
    • The Medical Foster Home study characterizes and evaluates the treatment of Veteran’s in the relatively less structured setting of a community foster home, which has been developed as an alternative to institutionally based long term care.
  • Health-system partner(s) (geriatrics, CLCs, etc) are actively engaged at the outset of the research to speed up implementation of research findings

Finally...

Interested in learning more about VA healthcare research? www.research.va.gov

VA's Caregiver Support Program

Meg Kabat, LCSW-C, CCM
Deputy Director, Caregiver Support Program
Department of Veterans Affairs

VA's Caregiver Support Program

• Allow Veterans to remain at home in the community
• Address specific needs of Family Caregivers with a menu of programs and services
• Promote Veteran & Caregiver health and well-being
• Provide one location to obtain needed information
• Provide training & information on common conditions
• Reduce isolation with professional & peer support
• Provide options to give Caregivers respite
• Sensitize health care providers to the Caregivers’ role

Caregiver Support Coordinators

• At all VA medical centers
• Clinical experts on Caregiver issues
• Knowledgeable about VA and non-VA resources
• Assist with application for new benefits
• Organize Caregiver focused activities and services
• Ensure Caregiver sensitivity is integrated into all programs
• Provide National Caregiver Support Line follow-up
• Establish programming for National Family Caregiver Month in November

Menu of VA Services

• In-Home Care
  • Skilled Nursing
  • Home Health Aide
  • Home Based Primary Care
  • Veteran Directed Home & Community Based Care
• Respite Care Services to Address Mobility Issues
  • Equipment
  • Home Modification
  • Automobile Modification
• Education and Training Financial Support
  • Aid and Attendance
  • Caregiver Stipend (Post 9-11)
• Information and Referral
  • Caregiver Web site: www.caregiver.va.gov
  • Caregiver Support Line
• Caregiver Support
  • Support Groups
  • Caregiver Support Coordinators
  • Interactive Website
  • Peer Mentoring Program

Caregiver Support Line

• 1-855-260-3274
• Over 64,000 calls received to date
• Averaging 100-150 calls per day
• Staffed by licensed social workers
• 24/7 coverage
• Follow-up provided by local Caregiver Support Coordinators
• Consistently positive comments and appreciation from Caregivers

Caregiver Support Program Website

• www.caregiver.va.gov
• Provides zip code based interactive Caregiver Support Coordinator locator
• Contact info for Support Line
• “Caregiver Toolbox”
• Caregiver “connections” with stories from peer Caregivers
• Link to application for post 9/11 benefits/services with live chat support
• Videos of Family Caregivers and Veterans
• Averaging 1,200 visits per day with 3 pages viewed during a visit

Caregiver Education and Training, Expanding Evidence -Based Best Practices

• REACH VA (Resources for Enhancing All Caregiver’s Health)
  • Designed to provide education support, and teach problem-solving for Caregivers of Veterans with Alzheimer’s Disease/dementia
  • Modified for use with Caregivers of Veterans with Spinal Cord Injury
  • Currently available at 78 sites, with additional sites in training
  • Recently modified to use more targeted intervention for a shorter period of time, allowing for larger scale implementation
• Building Better Caregivers
  • An interactive, web based workshop developed by Stanford University to be launched by VA Caregiver Support Program through a partnership with the National Council on Aging (NCoA) in Spring 2013
  • Workshop is designed to provide education, support and teach problem solving to Caregivers of Veterans of all eras 
  • Trained moderators facilitate the program and courses
  • Six week workshop topics include: stress management, difficult behaviors, sleep, healthy eating, exercise, difficult emotions for both the care recipient and Caregiver, decision making, resources, and planning for the future  

Caregiver Support

• Peer Support Mentoring Program
  • Launched January 2012
  • New Caregivers are matched to more experienced Caregivers
  • Mentors are registered volunteers at their local VA
  • Mentors receive additional orientation and on-going support from the National Peer Support Mentoring Program Manager
  • Peer Mentor/Caregiver dyads are contacted regularly by the local Caregiver Support Coordinators and the Peer Support Mentoring Program Manager to ensure successful matches
  • 29 Peer Mentor/Caregiver dyads are underway with additional Mentors in training
  • Anticipate 50 Peer Mentor/Caregiver dyads by the end of FY13

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