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Alzheimer’s Disease Coordinated Care for Hispanic and Latino Seniors

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UCLA CTSI and University of Minnesota Cross-Institutional Award Projects

Principal Investigators: Joshua Chodosh (UCLA) and Joseph Gaugler (University of Minnesota)

In the next decade Latinos will make up the largest racial/ethnic minority group among U.S. adults 65 years and older. However, Latino older adults face a number of challenges, including increased burden of chronic illness and limited access to health care. This extends to Alzheimer’s disease or related disorders; the prevalence of dementia among Latinos is potentially higher than in other racial/ethnic groups as symptom onset has been shown to occur six to seven years earlier in Latinos than in non-Latinos. The objective of this cross-institutional project is to ascertain the feasibility, acceptability, and utility of the Alzheimer’s Disease Coordinated Care for Hispanic and Latino seniors intervention (ADC-HL), a community-centered, dementia care management protocol designed to reduce caregiver burden as well as dementia-related symptoms (e.g., behavioral disturbances) in 15 persons with memory loss for Hispanic/Latino families in St. Paul, Minnesota. Innovative components of this project include a focus on dementia care in an underserved community, the use of mixed methods to collect and analyze a range of qualitative and quantitative process data, and reliance on an evidence-informed approach to build and refine a coordinated care management protocol for Hispanics/Latinos with dementia and their families.

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Alzheimer’s Disease Coordinated Care for Hispanic and Latino Seniors

  1. 1. 1 Alzheimer’s Disease Coordinated Care for Hispanic and Latino Seniors: Pilot Implementation JOSEPH E. GAUGLER, PH.D. ASSOCIATE PROFESSOR MCKNIGHT PRESIDENTIAL FELLOW SCHOOL OF NURSING UNIVERSITY OF MINNESOTA JOSHUA CHODOSH, MD, MSHS ASSOCIATE PROFESSOR OF MEDICINE DAVID GEFFEN SCHOOL OF MEDICINE AT UCLA VA GREATER LOS ANGELES HEALTH SYSTEM, GRECC ASSISTANT CHIEF OF STAFF/PATIENT SAFETY
  2. 2. ACKNOWLEDGEMENTS •  The UCLA and University of Minnesota Clinical and  Transla8onal Science Ins8tutes  •  Ana Diaz, MD, of Payne Phalen Block Nurse Program,  St. Paul, MN 
  3. 3. OVERVIEW  •  Demen8a prevalence is high among US La8no popula8ons  and onset is oLen at earlier age  •  Problems are magnified by poverty and poor access to  healthcare services  •  ADC‐HL is a transla8on of the Alzheimer’s disease  Coordinated Care for San Diego Seniors (ACCESS) study  (Vickrey, PI)  •  The ADC‐HL is a community‐centered, demen8a care  management protocol designed to reduce caregiver burden  and challenging, demen8a‐related symptoms (e.g.,  behavioral disturbances) in La8no/Hispanic families. 
  4. 4. OBJECTIVE  •  To ascertain the feasibility of the Alzheimer’s Disease  Coordinated Care for Hispanic and La8no Seniors interven8on  (ADC‐HL) in St. Paul, MN.    •  To develop a care management program with the best  opportunity to achieve the greatest relevance and  effec8veness for this popula8on  •  To reduce caregiver burden and challenging, demen8a‐related  symptoms (e.g., behavioral disturbances) in La8no/Hispanic  families.   •  To develop strong collabora8ve processes between UM and  UCLA for future transla8onal research in demen8a within  La8no/Hispanic communi8es 
  5. 5. SPECIFIC AIMS  •  Complete a feasibility study of the ADC‐HL with 17 Hispanic or  La8no demen8a caregivers that collects informa8on on fidelity  of ADC‐HL implementa8on, ADC‐HL uptake by family  caregivers, and ADC‐HL impact on everyday caregiver ac8ons/ behaviors.  •  Measure changes in key outcomes that ADC‐HL is designed to  improve, including reducing the severity of demen8a symptoms  for persons with Memory loss (PWMLs), health service use for  PWMLs, and self‐reported family caregiver stress, mood, and  quality of family care processes over a 4‐month period. 
  6. 6. SIGNIFICANCE  •  Over 5 million individuals in the U.S. have Alzheimer’s disease  and related demen8as   •  Significant burden across families.   •  Prevalence among Hispanic/La8nos is poten8ally higher than  in other racial/ethnic groups with symptom onset occurring  6‐7 years earlier than in non‐Hispanic/La8nos.   •  Hispanic/La8no popula8on > 65 yrs will be the largest racial/ ethnic minority among older adults in the U.S. by 2019  •  19.8% of U.S. older adults by 2050.   •  Lack of accultura8on and socioeconomic barriers =  exacerbated demen8a care in Hispanic/La8no communi8es.  
  7. 7. PREVIOUS & PRELIMINARY STUDIES: ACCESS Vickrey, et al. Ann Intern Med. 2006;145 713‐26 
  8. 8. PREVIOUS & PRELIMINARY STUDIES: ACCESS  PATIENT AND CAREGIVER HEALTH  8 Usual Care  Mean  Interven8on  Mean  Adjusted  Between‐ Group  Difference  P ‐Value  Pa8ent’s health related quality of  life (0‐1 range)  0.03  0.10  0.06  0.03  Overall quality of healthcare (0‐10  range)  7.9  8.2  0.5  0.003  Caregiver Confidence in Caregiving  (0‐100 range)  60  67  6.4  0.001  Caregiving‐anributable Health  Strain (0‐100 range)  60  64  4.3  0.06  * Higher scores mean bener outcomes  Vickrey, et al. Annals 2006;145:713‐726. 
  9. 9. PREVIOUS & PRELIMINARY STUDIES: ACCESS  Teams Produce Bener Quality DCM= Demen8a Care Manager; Community= All 3 components  together   Chodosh, et al. Am J Man Care 2012;18:85‐94. 
  10. 10. PREVIOUS & PRELIMINARY STUDIES: V‐CAMP  Ac#ons Taken  % Referrals  Requested%  Comprehensive assessment  100%  62.7%  Blood pressure management  32.8%  0%  Hearing assessment/interven8on  26.9%  0%  New demen8a diagnosis  26.9%  62.7%  Exercise rou8ne provided  26.9%  0%  Physical therapy ordered  23.9%  0%  Advance care planning  23.9%  0%  Driving recommenda8ons  22.4%  0%  An8cholinergic/Benzo reduc8on  22.4%  0%  Incon8nence assessment / therapy  19.4%  0%  ID bracelet provided  17.9%  0%  Sleep management  16.4%  0%  ACh‐I Discon8nued  16.4%  0%  10
  11. 11. PREVIOUS & PRELIMINARY STUDIES:  Compara8ve Effec8veness of Demen8a Care Strategies in  Underserved Communi8es  •  Care management comparing community‐based (in person) versus  telephone‐only care  •  San Fernando Valley – Predominantly La8no immigrant  underserved community  •  Preliminary findings:    Large service needs    Vast educa8onal gaps    Socioeconomic pressures    Immigra8on challenges    Percep8on of need differs between caregiver and care manager    Enrollment challenges    Even larger follow‐up challenges 
  12. 12. ADDITIONAL POINTS OF INNOVATION •  A focus on demen8a care in an underserved community  •  Use of mixed methods design  •  Applica8on of new assessment tools for greater efficiency but  needing feedback from caregivers / care managers  •  Restructuring of care management process to achieve greater  clarity for caregivers immersed in the process, care managers  learning the process, and for educa8ng others 
  13. 13. APPROACH •  Phase I. Training. Videoconference training of Dr. Diaz over a 2 month period •  Phase II. Feasibility study. Enroll 17 family caregivers of persons with memory loss from PPBN in east St. Paul, MN 1. Baseline assessment (RAM, HABC-Monitor, service use, use of anti-dementia drugs, sociodemographics) 2. Implementation of ADC-HL protocol. 3. 4-Month assessment (RAM, HABC-Monitor, service use, use of anti-dementia drugs) 4. Post-ADC-HL focus group to examine ADC-HL uptake and impact as perceived by family caregiver participants.
  14. 14. ANALYSIS •  Feasibility analysis: Specific Aim 1.   Univariate, descriptive statistics will be conducted to examine empirical process data (e.g., duration and frequency of ADC-HL care coordination use) to examine the feasibility of the ADC-HL.   In addition, thematic content analysis of focus group data will take place to determine barriers to ADC-HL use as well as why the ADC-HL does or does not work for participants
  15. 15. ANALYSIS •  Descriptive longitudinal analysis: Specific Aim 2.   Cronbach's alpha (α) estimates will examine reliability of all summed measures.   Each outcome variable will be examined to determine if skewness exists or outliers are present. Normal probability plots and histograms of each dependent variable will be analyzed.   Data available at baseline and 4 months will also allow for longitudinal analyses of rate of change in key outcomes: i.e., the various domains assessed by the RAM and HABC-Monitor, health service use, and acetylcholinesterase inhibitor use.   A classic repeated measures analysis of variance will be conducted using SPSS.   Additional analyses will determine if covariates (e.g., sociodemographics) are correlated with change in ADC-HL outcomes during the 4-month study period.
  16. 16. FUTURE PLANS •  Preliminary results will support translational research proposal in response to PA-11-123: Translational Research to Help Older Adults Maintain their Health and Independence in the Community R01. •  Feasibility data from this project along with Los Angeles-based comparative effectiveness evaluation will provide strong preliminary data for a multi-site translational project of ADC-HL. •  We will leverage several existing University of Minnesota/UCLA CTSI resources.   Delaware Clinical Research Unit   Communuity Engagement for Health at the University of Minnesota and UCLA’s sister office   The CTSI Biostatistical Design and Analysis Center will be utilized for the subsequent R01 proposal
  17. 17. QUESTIONS?  Joseph E. Gaugler, Ph.D.  Phone: 612‐626‐2485  Email: gaug0015@umn.edu  Joshua Chodosh, MD, MSHS  Phone: 310‐268‐3361  Email: JChodosh@mednet.ucla.edu  

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