Monday, February 28, 2011

Meeting Our Obligation to Caregivers - the REACH VA Study


I’m tired of innovative health care interventions targeted at those caring for the more than 5 million individuals living with dementia. It’s not that I don’t think they are important. Rather, I find it rather pointless work if these interventions can’t be translated into real world applications. Today, though, the Archives of Internal Medicine is publishing an important study that adapts and implements a multicomponent caregiver intervention into one of the largest health care organizations in the US - the Veterans Health Administration (VHA).

The study, authored by Olivia Nichols and colleagues, translates the Resources for Enhancing Alzheimer's Caregivers Health (REACH II) intervention into the VHA system. The initial REACH II randomized control trial showed significant improvement in caregiver burden, depression, health/self-care, social support, and management of patient behaviors. Caregivers also got something that is worth its weight in gold - one extra hour per day not spent in caregiving tasks.

The current prospective translational study, put into practice a modified REACH II intervention into 24 VA Home Based Primary Care programs in 15 different states.  The modified intervention (REACH VA) basically consisted of 9 one-hour individual home sessions and three half-an-hour telephone sessions, and five one-hour monthly telephone support group sessions. The focus of the sessions was on education, support, and skills training to address 5 caregiving risk areas: “safety, social support, problem behaviors, depression, and caregiver health.” All of the sessions were conducted by VA staff trained in the intervention, most of whom were social workers, psychologists, or nurses at their respective facilities.

To be eligible for the study, selected patients must have had dementia with at least one activities of daily living limitation or two or more instrumental activities of daily living limitations. To meet inclusion criteria, they also must have had a co-resident family caregiver that provided greater than 4 hours of care per day for at least 6 months. Caregivers also had to endorse two caregiving stress behaviors (i.e being overwhelmed, often needing to cry, angry or frustrated, etc).

The results revealed that the REACH II study can be implemented in a real world setting, and showed significant reductions at 6 months in caregiver frustration, burden, depression, and the number of troubling dementia related behaviors. The vast majority (96%) of caregivers felt the program should be provided by VA to caregivers

So what is the next step? In the Archives commentary that I wrote with Ken Covinsky on this study, we argue that “if health systems are going to increasingly rely on family caregivers to deliver complex care, then they have they have an obligations to aid caregivers in this task and reduce the personal costs associated with it”. The VA is taking the lead in this regard. The question remains – will others follow?

by: Eric Widera

2 comments:

Carol Levine said...

Thanks to Eric Widera and Ken Covinsky for their splendid commentary in support of family caregivers. Although there has been a greater recognition of the importance of family caregivers since I published the essay in NEJM cited in the article, these unpaid partners are still often invisible in health care settings or considered annoyances or intruders. At the United Hospital Fund we are nearing the end of a 15-month Transitions in Care-Quality Improvement Collaborative (TC-QuIC), which has focused on developing better ways to include family caregivers in developing and implementing effective transition plans. The 28 hospital, rehab, home care, and hospice teams are using the free guides for family caregivers (in four languages) and for health care professionals from the Next Step in Care website (www.nextstepincare.org. One guide of particular interest for Alzheimer's patients and caregivers is the provider guide to reducing the http://www.nextstepincare.org/uploads/File/Guides/Provider/Provider_Dementia.pdfstress of hospitalization

There are many ways to support caregivers; acknowledging their imiportance and helping them articulate their own needs are good first steps.
Carol Levine
clevine@uhfnyc.org

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