Comparative Effectiveness of Dementia Care Strategies in Underserved Communities

描述（由申请人提供）：虽然痴呆症给美国500多万人及其护理人员带来了深刻的人类痛苦和经济负担，但这些影响在低收入社区被放大了。痴呆症护理管理——社会工作者或护士进行结构化评估，并与患者和护理人员合作，发现问题，并持续执行个性化的管理方案——已被证明在诊所或家访和电话相结合的情况下，可以提高护理的质量和结果。然而，随着成本控制压力的增加，医疗保健系统面临越来越大的压力，要求提供更便宜的护理管理，即完全通过电话。然而，在拉丁裔移民社区，文化、语言和教育障碍可能意味着需要在家庭和社区环境中进行更密集和面对面的互动，以使护理接受者和护理人员参与进来，以便从护理管理中受益。在这项随机试验中，将比较两种不同的痴呆护理管理方案的实施策略。以社区为中心的护理管理战略将使医疗保健组织的护理经理与阿尔茨海默氏症协会的护理经理结成伙伴，他们将通过家访和在当地设施的面对面会议合作提供护理管理。在比较策略中，医疗保健组织的单个护理经理将为相同数量的参与者提供基于协议的电话护理管理。来自洛杉矶一个经济贫困的拉美裔社区的250名患者/护理人员将被随机选取并随访12个月。目的是：(1)检验以社区为中心的痴呆症护理管理策略与仅电话护理管理策略相比，是否能降低护理者的负担和减少护理对象的挑战性行为。我们假设，以社区为中心的策略将产生更好的结果，因为在社区环境或家中亲自提供护理管理有更大的文化基础；(2)检验以社区为中心的照护管理策略与仅电话照护管理策略是否更有利于参与者的保留。我们假设以社区为中心的护理管理将更成功地保留；(3)对成本进行比较，并对两种战略进行成本效益分析。我们假设，以社区为中心的策略将花费更多，但将产生更大的减少照顾者的负担和在照顾者的问题行为。研究结果将为痴呆症护理管理策略的相对有效性及其成本提供新的知识，主要是在公共安全网系统中的拉丁裔社区。它将衡量照顾者的负担和受照顾者的问题行为，这两者都与昂贵的制度化有关。随着痴呆症的负担日益加重，这些数据对于公共安全网设置的管理人员至关重要，有助于在高度受限的财政环境下决定护理提供战略的相对价值。

DESCRIPTION (provided by applicant): While dementia carries profound implications for human suffering and economic burdens among more than 5 million people in the US and their caregivers, these implications are magnified in low-income communities. Dementia care management - in which social workers or nurses conduct structured assessments and work with patients and caregivers to identify problems and execute individually-tailored management protocols on an ongoing basis - has been proven to improve quality and outcomes of care when delivered in a clinic or as a combination of home visits and telephone. However, with growing cost-containment pressures, healthcare systems are increasingly pressured to deliver care management less expensively, i.e, exclusively by telephone. Yet, in Latino immigrant communities, cultural, language and educational barriers may mean that more intensive and in-person interactions at home and in community settings are needed to engage care recipients and caregivers in order to benefit from care management. In this randomized trial, two different strategies for delivery of dementia care management protocols will be compared. A community-centered care management strategy will partner a healthcare organization care manager with one from the Alzheimer's Association, who will collaborate in providing care management through home visits and in-person meetings at local facilities. In the comparison strategy, a single care manager at the healthcare organization will provide protocol-based telephone care management for the same number of participants. 250 patient/caregiver dyads from an economically-impoverished, predominantly Latino community in Los Angeles will be randomized and followed for 12 months. Aims are: (1) to test whether a community-centered dementia care management strategy compared to a telephone-only care management strategy yields lower caregiver burden and fewer challenging behaviors in care recipients. We hypothesize that the community-centered strategy will produce better outcomes due to greater cultural grounding from in-person delivery of care management in community settings or at home; (2) to test whether retention of participant dyads will be greater with a community- centered or a telephone-only care management strategy. We hypothesize that community-centered care management will be more successful in retention; and (3) to compare the costs and conduct a cost- effectiveness analysis of the two strategies. We hypothesize that the community-centered strategy will cost more but will produce greater reductions in caregiver burden and in problem behaviors in the care recipient. Findings will provide new knowledge on relative effectiveness of dementia care management strategies and their costs, in a predominantly Latino community in the public safety net system. It will measure caregiver burden and problem behaviors in care recipients, both of which are linked to costly institutionalization. With dementia's growing burden, these data will be critically important to administrators in public safety net settings, for decisions about the relative value of care delivery strategies in a highly-constrained fiscal climate. PUBLIC HEALTH RELEVANCE: Dementia is a condition that is growing in prevalence and which harms not only the afflicted individual but also adversely affects the health of their family and other informal caregivers. New methods for delivering comprehensive assistance to persons with dementia and their caregivers are known to be effective and can delay nursing home placement, but this study will discover (1) whether more face-to-face involvement rather than telephone delivery of this assistance will work better among poor patients in Los Angeles, and (2) if one method is better than the other, what are the differences in costs between them. These data will enable administrators in public health care settings around the US and non-profit foundations addressing dementia patient and caregiver need to decide what method provides the best value and the best outcome relative to its cost.