The Alabama REACH Demonstration Project (ARDP) A case example using the RE-AIM model Lou Burgio, Ph.D. University of Alabama Center for Mental Health and Aging

RE-AIM

Background 2004, with AoA funds, ADSS started partnership with UA to modify REACH clinical trial protocol so that it is feasible in the community. Supervision of resulting treatment program would be by four Area Agencies on Aging (AAA), and case managers from AAAs would serve as interventionists.

Role of University Work with AAAs to design workable program: modify treatment manuals and procedures Train case workers to use intervention in clients’ homes. Be available by phone for case consultation Maintain data management and conduct data analysis

Resulting Intervention 1.Risk Assessment 2.Education about AD, Caregiving, and Stress 3.Caregiver Health(Health Passport) and Home Safety (use of checklist) 4.Behavior Management 5.Signal Breath (simple relaxation)

Procedural Modifications Four, hour-long home visits over a 3-4 month period Three phone calls interspersed among home visits

RE-AIM Application to ARDP What we did Factors to consider (suggested by RE-AIM)

RE-AIM

RE-AIM ELEMENTS: REACH Definition: The number, percent of target audience, and representativeness of those who participate. What we did: –Four AAAs chosen by ADSS: two rural and two urban –Of the 272 dyads present at first home visit, 97% attended all four home visits

RE-AIM ELEMENTS: REACH Factors to consider Need data on total number of caregivers contacted for participation Characteristics of caregivers who did and did not participate

RE-AIM ELEMENTS: EFFECTIVENESS Definition: Change in temporally appropriate outcomes, and impact on quality of life and any adverse outcomes.

Attrition Rates Completed enrollment forms (demographics):272 Completed initial visit:272 Completed second visit:270 Completed third visit:269 Completed the intervention:265 Completed final paperwork:236

Reasons that 36 families did not complete final paperwork 12 nursing home placements (3 hurricane related) 7 care recipient deaths 12 drop-outs “cause unknown” (3 probably hurricane related) 5 unaccounted for (likely due to staff turnover in year 1)

Treatment Effects on CG Emotional Well-Being NMean (SD) 1 Mean (SD) 2 t-valuep-valueEffect size d Zarit Burden Scale (higher = more burden) (.74) 2.23 (.65) Social Support past month (higher = better support) (.98) 3.16 (.82) Depression in the last week (higher = more depressed) (.86) 1.91 (.82) Positive Aspect of Caregiving (higher = more PAC) (1.07) 4.17 (1.01) ADL Stress (higher = more stress) (.78) 1.87 (.73) CG Bothered by CR mem/beh problems in the last week (higher = more bother) (1.43) 2.08 (1.29) Felt like screaming, yelling, hit/slap CR (higher = more stress) (.46) 1.26 (.38)

Overall Improvements in Behavioral Problems of the CR BaselineN=267Yes: 50 (19%)No: 217 (81%) Time Point 2 (T2) N=224Yes: 85 (38%)No: 139 (62%) Change over timeN=221 (cases excluded test-wise) No at Baseline & T2: 120 (54%) No at baseline, Yes at T2: 61 (28%) Yes at Baseline & T2: 24 (11%) Yes at Baseline, No at T2: 16 (7%) A McNemar Chi ‐ square test was used to evaluate the response to a question about overall improvement in behavioral problems in the CR over the past 4 months, at pre and post ‐ intervention. A statistically significant change over time was found (N = 221, X 2 =25.14, p<.001).

Improvement in Behavior Problems Post-treatment, caregivers reported significant improvement in behavior problems (p<.001)

Risk Behaviors We examined 5 risk behaviors Smoking Supervision of the CR Wandering Driving Access to Dangerous Objects We used within-subjects paired sample t-tests to examine change over time in 4 of these.

Four Risk Behaviors NMean (SD) 1 Mean (SD) 2 t-valuep-valueEffect size d Smoking (higher = more often) (.25) 1.03 (.20) Unsupervised (higher = more often) (.80) 1.42 (.63) Wandering (higher = more often) (.51) 1.14 (.39) Driving (higher = more often) (.27) 1.04 (.23)

Access to Dangerous Objects Time point 1 Time point 2 NoYes No15210 Yes4717 The remaining item (Does the CR have access to dangerous objects?) was examined using a McNemar Chi ‐ square test. With 226 people completing pre and post ‐ tests, 47 people who had previously had access to dangerous objects no longer had access. This change was found to be statistically significant (N = 226, X 2 =22.74, p.<.001).

Treatment Effects on Caregiver Health NMean (SD) 1 Mean (SD) 2 t-valuep-valueEffect size d Perceived change in Health (higher = worse health) (.64) 2.95 (.65) Sleep (higher = worse sleep) (.70) 2.11 (.69)

Client Satisfaction Survey Part I (strongly disagree) 1 – 4 (strongly agree)NMean (SD)Valid Percent Types (.51)99% responded 3-4 Quality (.43)98% responded 3-4 Information (.42)98% responded 3-4

Client Satisfaction Survey Part II (very helpful) 1 – 3 (not helpful)NMean (SD)Valid Percent Info about AD (.42)78% responded 1; 22% responded 2 Info CG and Stress (.47)73% responded 1; 26% responded 2 Home safety (.57)60% responded 1; 36% responded 2 Health passport (.55)57% responded 1; 40% responded 2 Behavioral Prescriptions (.59)54% responded 1; 43% responded 2 Signal Breath (.59)53% responded 1; 41% responded 2

Client Satisfaction Survey Part III 1 (too many); 2 (too few); 3 (about right)NMean (SD)Valid Percent # home visits (.46)81% responded 3; 17% responded 2 # phone calls (.46)87% responded 3; 9% responded 2

RE-AIM ELEMENTS: EFFECTIVENESS Factors to consider Are any caregiver or case manager factors associated with outcome? Is there any negative impact of intervention? Can program be shortened? Component analysis? Input by case managers and caregivers?

RE-AIM ELEMENTS: ADOPTION Definition: Number, percent and representativeness of settings and clinicians who participate. What we did: –Near the end of the project, every case manager in Alabama was taught REACH intervention in two- day workshop (all AAAs involved)

RE-AIM ELEMENTS: ADOPTION Factors to consider How many AAAs were using REACH intervention after the state-wide workshop? How many case managers within AAAs actually used REACH interventions after state-wide workshop? What were the characteristics of those who did and those who did not?

RE-AIM ELEMENTS: IMPLEMENTATION Definition: Extent to which a program or policy is delivered consistently; what are the time investment and costs of the program. What we did: –A form was used by case managers to track the number of home visits/phone calls, but also to record therapeutic activities during the visits –Case managers reported using the treatment components from 88.6% (caregiver passport) to 98.5% (safety checklist) of the time

RE-AIM ELEMENTS: IMPLEMENTATION Factors to consider The program would benefit from assessment of implementation costs to inform future allocations

RE-AIM ELEMENTS: MAINTENANCE Definition: Individual/member target: Long-term effects and attrition.Setting/clinician: Extent of discontinuation, modification, or sustainability of program. What we did: –Integrated REACH into Alabama CARES –CARES is long-standing program that offers menu of services; REACH is now one of the services available –All CARES team members attended two-day workshop to learn about REACH intervention

RE-AIM ELEMENTS: MAINTENANCE Factors to consider Need longer assessment of individual client maintenance Need assessment of length of time agencies kept REACH “active” within CARES Need application to other senior services, e.g. Senior Day Services