Comparative Effectiveness of Dementia Care Strategies in Underserved Communities

描述(申请人提供)：尽管痴呆症对美国500多万人及其照顾者的痛苦和经济负担有着深远的影响，但这些影响在低收入社区被放大。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，持续发现问题并执行个性化的管理方案--已被证明在诊所提供或作为家访和电话的组合提供时，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，医疗保健系统越来越有压力以更低的成本提供护理管理，即完全通过电话提供。然而，在拉美裔移民社区，文化、语言和教育障碍可能意味着需要在家里和社区环境中进行更密集的面对面互动，以吸引护理接受者和照顾者，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症护理管理方案的交付策略。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一名护理经理合作，后者将通过家访和在当地设施举行面对面会议来合作提供护理管理。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、以拉丁裔为主的社区的250名患者/照顾者将被随机抽样，并进行为期12个月的跟踪调查。目的是：(1)测试以社区为中心的痴呆症护理管理策略与仅使用电话的护理管理策略相比是否产生更低的照顾者负担和更少的挑战性行为。我们假设以社区为中心的策略将产生更好的结果，因为更多的文化基础来自于在社区环境中或在家中面对面提供护理管理；(2)测试以社区为中心的护理管理策略或仅使用电话的护理管理策略是否会更好地保留参与者二元组。我们假设，以社区为中心的护理管理在留存方面会更成功；以及(3)比较两种策略的成本并进行成本效益分析。我们假设，以社区为中心的策略将花费更多，但将在照顾者负担和照顾者问题行为方面产生更大的减少。这些发现将为公共安全网系统中以拉丁裔为主的社区中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。它将衡量照顾者的负担和护理接受者的问题行为，这两者都与昂贵的制度化有关。随着痴呆症负担的增加，这些数据将对公共安全网环境中的管理者至关重要，对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至关重要。 与公共卫生的相关性：痴呆症是一种患病率越来越高的疾病，不仅对患病个人造成伤害，而且对其家人和其他非正式照顾者的健康产生不利影响。众所周知，向痴呆症患者及其照顾者提供全面援助的新方法是有效的，可能会推迟养老院的安置，但这项研究将发现(1)在洛杉矶的贫困患者中，更多的面对面参与而不是电话提供这种援助是否会更有效，(2)如果一种方法比另一种方法更好，它们之间的成本差异是什么。这些数据将使美国各地公共卫生保健机构的管理者和解决痴呆症患者和照顾者需要的非营利性基金会能够决定哪种方法提供最好的价值和相对于其成本的最佳结果。

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.