Improving Outcomes for Family Caregivers and Older Adults with Complex Conditions: The Adult Day Service Plus Program

 描述(申请人提供)：近5000万个家庭为患有复杂慢性病的老年人提供超过85%的长期护理。家庭照顾者(CG)通常在没有培训或支持的情况下承担护理责任，本身可能会经历包括抑郁症在内的多种健康风险。确定接触到这一庞大人口的创新方法，并提供以证据为基础的支持性计划，以提高他们的福祉，是公共卫生的当务之急。接触CGS的一种方法是通过循证计划来增强现有的社区服务。成人日间服务(ADS)是一种日益增长的、基于社区的关键选择，患有复杂疾病的老年人的CGs依赖于此。ADS计划提供户外、有监督的活动，但通常不提供基于证据的支持性CG计划。此外，广告的使用并不总是与CG抑郁症状、客户行为症状和疗养院入院人数的减少相关。因此，ADS是一个理想的“试验台”，用于将经过验证的CG干预措施转化为接触和支持服务不足的CG。我们之前在一个小型试验中开发和评估了ADS Plus，这是一个通过系统支持(例如，教育、技能培养)来增强ADS的计划。我们发现，与通常的ADS相比，ADS Plus减少了CG抑郁和养老院安置。针对NIA PA-14-161呼吁进行转化性研究，将循证模型整合到现有服务中，我们提出了一个实用的试验设计，以评估ADS Plus的有效性和大规模应用。我们将涉及美国各地不同地理位置和人员配备水平的30个ADS项目和300个CG(ADS Plus站点150个；ADS普通护理站点150个)。我们将使用分组和重新随机化技术、混合方法和成本分析来严格评估计划的有效性和实施过程。如果有效，并与主要广告负责人组成的翻译咨询委员会进行磋商，ADS Plus将得到广泛传播。主要研究目的是：1)评估与6个月后常规ADS相比，ADS Plus改善CG幸福感和减少抑郁症状的有效性(假设1：与仅使用常规ADS相比，ADS Plus中的CGS将报告改善幸福感和减少抑郁症状)；以及2)评估12个月时ADS Plus对CG幸福感和抑郁症状的长期维持效果(假设2：使用ADS Plus的CGS将保持6至12个月的益处)。其他研究目标将：3)评估使用ADS Plus的CGs是否比在12个月内使用常规ADS的CGs更有可能在ADS中保留亲属，而不是将他们安置在住宅环境中；4)估计ADS Plus的成本，并评估其在6个月和12个月时是否与通常的ADS相比产生净经济效益；5)评估ADS Plus对客户行为和CG疗效以及心烦意乱管理症状的影响；以及6)评估从理论上得出的(RE-AIM，压力过程模型)治疗变化的中介途径，包括12个月内CG的接受度和员工对ADS Plus的采用。

 DESCRIPTION (provided by applicant): Close to 50 million families provide more than 85% of long-term care to older adults with complex chronic conditions. Family caregivers (CGs) typically assume care responsibilities without training or support and may in turn experience multiple health risks themselves including depression. Identifying innovative approaches for reaching this large population and providing evidence-based supportive programs to enhance their well-being is a public health imperative. One approach to reach CGs is to augment existing community-based services with an evidence-based program. Adult day service (ADS) is one such growing and critical community-based option that CGs of older adults with complex conditions rely on. ADS programs offer out-of-home, supervised activities but do not routinely provide evidence-based supportive CG programs. Also ADS use is not consistently associated with reductions in CG depressive symptoms, client behavioral symptoms and nursing home admissions. Thus, ADS is an ideal "test bed" for translating a proven CG intervention to reach and support underserved CGs. We previously developed and evaluated in a small trial, ADS Plus, a program augmenting ADS with systematic support (e.g., education, skill building) to CGs. We showed that ADS Plus in comparison to usual ADS, reduced CG depression and nursing home placement. In response to NIA PA-14- 161 calling for translational research to integrate evidence-based models into existing services, we propose a practical trial design to assess the effectiveness and uptake of ADS Plus on a large scale. We will involve 30 ADS programs throughout the U.S. varying in geographic location and staffing levels and 300 CGs (150 in ADS Plus sites; 150 in ADS usual care sites). We will use cluster and re-randomization techniques, mixed methods, and cost analyses to rigorously evaluate program effectiveness and implementation processes. If effective, and with consultation from a Translation Advisory Board of key ADS leaders, ADS Plus will be disseminated widely. Primary study aims are to: 1) evaluate the effectiveness of ADS Plus to improve CG well-being and reduce depressive symptoms compared to routine ADS use at 6 months (Hypothesis 1: CGs in ADS Plus will report improved well-being and reductions in depressive symptoms compared to those in routine ADS only); and 2) evaluate long-term maintenance effects of ADS Plus at 12 months on CG well-being and depressive symptoms (Hypothesis 2: CGs using ADS Plus will maintain benefits from 6 to 12 months). Additional study aims will: 3) evaluate whether CGs using ADS Plus are more likely to maintain relatives in ADS and less likely to place them in residential settings compared to those in routine ADS over 12 months; 4) estimate ADS Plus costs and assess whether it results in net financial benefits when compared to usual ADS at 6 and 12 months; 5) evaluate the effects of ADS Plus on client behaviors and CG efficacy and upset managing symptoms; and 6) evaluate theoretically-derived (RE-AIM, Stress Process Model) mediational pathways of treatment change including CG acceptance and staff adoption of ADS Plus over 12 months.