1. Engaging Important Stakeholders to Assess Gaps in Primary Care for Dementia: Considering the Forest as well as the Trees Christina L. Vair, PhD, Clinical Research Psychologist, VA Center for Integrated Healthcare Laura O. Wray, PhD, Executive Director, VA Center for Integrated Healthcare Gregory P. Beehler, MA, PhD, Clinical Research Psychologist, VA Center for Integrated Healthcare J. Riley McCarten, MD, VISN 23 GRECC Medical Director Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Session # E2b October 16, 2015

2. Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

3. Learning Objectives At the conclusion of this session, the participant will be able to: Identify important stakeholders within their local setting, including ways to conduct a stakeholder analysis and how to engage stakeholders in addressing program evaluation questions. Describe the VHA’s interdisciplinary, team-based approach for whole- person care (Patient Aligned Care Teams and Primary Care-Mental Health Integration) and ways that these partnerships could be utilized in support of integrated care, system transformation, and population health for veterans with dementia. Discuss notable barriers and facilitators to the provision of high quality dementia care within primary care behavioral health models of service delivery and ways to improve quality of PC healthcare services for patients with dementia through engagement of important stakeholders.

4. Bibliography / References 1.Cordell, C. B., Borson, S., Boustani, M., Chodosh, J., Reuben, D., Verghese, J. et al. (2013). Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimer’s & Dementia, 9, 141–150. 2.Galvin, J. E., & Sadowsky, C. H. (2012). Practical guidelines for the recognition and diagnosis of dementia. Journal of the American Board of Family Medicine, 25, 267–382. 3.McCarten, J. R., & Borson, S. (2014). Should family physicians routinely screen patients for cognitive impairment? YES: Screening is the first step toward improving care. American Family Physician, 89(11), 861-62. 4.Wilcock, J., Jain, P., Griffin, M., Thuné-Boyle, I., Lefford, F., Rapp, D., & Iliffe, S. (2015). Diagnosis and management of dementia in family practice. Aging & Mental Health, (ahead-of-print), 1-8. 5.Wray, L. O, Wade, M., Beehler, G. P., Hershey, L., & Vair, C. L. (2014). A program to improve identification of undiagnosed dementia in primary care and its association with health care utilization. American Journal of Geriatric Psychiatry, 22, 1282-1291.

5. Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

6. Disclosure The views expressed in this presentation are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

7. Goals for Presentation Detail steps taken to identify and engage important stakeholders Interactive audience participation to address strategies that can be utilized to partner with and address the unique needs of their stakeholders

8. SUPPORT STRUCTURES Principles Underlying VA Care

9. Dementia in Primary Care Dementia is a significant public health concern, though rates of detection of dementia in primary care (PC) remain low Failure to adequately address dementia can result in poor outcomes – higher health care utilization – decreased quality of life for patients and families Systems transformation and innovation are needed to provide high quality, whole-person care for patients with dementia and their families

10. System Innovations in the VHA Patient Aligned Care Teams Primary Care-Mental Health Integration

11. Patient Aligned Care Team (PACT) Access Offer same day appointments Increase shared medical appointments Increase non- appointment care Access Offer same day appointments Increase shared medical appointments Increase non- appointment care Practice Redesign Redesign team: o Roles o Tasks Enhance: o Communication o Teamwork Improve Processes: o Visit work o Non-visit work Practice Redesign Redesign team: o Roles o Tasks Enhance: o Communication o Teamwork Improve Processes: o Visit work o Non-visit work Care Management & Coordination Focus on high-risk pts: o Identify o Manage o Coordinate Improve care for: o Prevention o Chronic disease Improve transitions between PACT and: o Inpatient o Specialty o Broader Team Care Management & Coordination Focus on high-risk pts: o Identify o Manage o Coordinate Improve care for: o Prevention o Chronic disease Improve transitions between PACT and: o Inpatient o Specialty o Broader Team Patient Centeredness: Mindset and Tools Improvement: Systems Redesign, VA TAMMCS Resources: Technology, Staff, Space, Community

12. PC-MHI The overall purpose of the Primary Care-Mental Health Integration (PC-MHI) initiative is to integrate care for Veterans’ physical and mental health conditions, improve access and quality of care across the spectrum of illness severity, and allow treatment in mental health specialty settings to focus on persons with more severe mental illnesses.

13. Primary Care Provider Dementia Detection in PC Behavioral Telehealth Center (BTC) Dementia Care Manager Geriatric Evaluation & Management (GEM) Clinical Reminder used to generate monthly RAPID eligible list + + + +/- 13 VISN 2 RAPID Program Overview

14. Understanding the Implementation Environment Environment that is conducive to high quality, patient-centered care for veterans with dementia. – Uptake & adoption hinge on the healthcare environment into which they are implemented – This includes attitudes of key stakeholders, including patients, families, providers, and administrators

15. Improvement-Focused Approach Focus on program improvement Goal to serve the needs of stakeholders, provide valid information, offer alternative points of view to those on the frontlines serving patients – Need to balance recognition of strengths of programs as well as areas for improvement “To carry this off without threatening the staff is the most challenging aspect of program evaluation.” (Posavac & Carey, 2007)

16. Stakeholder Involvement Who are your important stakeholders? Ways to engage Important role for stakeholders in program evaluation

17. Themes from Gaps Study Conducted focus groups and individual interviews with key stakeholders who work within, and use, the VHA Themes addressing barriers and facilitators to high quality dementia care Focus on themes identified in interviews with PCPs, RNs, BHPs

18. Identified Barriers

19. Identified Facilitators

20. Q & A Current practices in your setting to address dementia – Detection – Diagnosis – On-going care

21. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!