Dementia is a common, multifaceted problem with significant implications for function and quality of life among older individuals. Current demographic shifts are magnifying this problem. Particularly troubling are neuropsychiatric symptoms, which, in addition to creating caregiver distress, also are linked to functional decline, institutionalization, higher health care costs, and mortality (even after controlling for other potential confounders and severity of cognitive impairment). Furthermore, dementia is often unrecognized and underdiagnosed, and patients with dementia historically have poor access to care, particularly those living in rural areas.
The Geriatrics/Dementia Clinic at the Baltimore Veterans Affairs Medical Center (BVAMC) is a referral resource that provides extensive, multidisciplinary evaluations as well as coordinated subspecialist and interprofessional case review. A diverse group of clinicians (representing geriatrics, geriatric psychiatry, neuropsychology, clinical pharmacy, nursing, and social work) perform a half-day evaluation, followed by a meeting of the interdisciplinary team, and feedback session where patients and their families are given the results of the testing and diagnostic impressions as well as plans for further evaluation and treatment. Finally, in addition to the benefits it provides to veterans and their families, this clinic has proven to be an important resource for professional trainees.
Yet this model can be difficult to access, and those living in more remote regions had challenges availing themselves of this resource. Often, they would have to wake before dawn to drive 2 to 4 hours to the medical center. Furthermore, despite the many obvious benefits of this comprehensive approach, veterans and their families often left the clinic with a staggering amount of information and numerous recommendations for future care but without the assurance of integrated follow-up (a burden borne particularly by those living remotely).
The DEMO Program
In response to the dual challenges of access to and coordination of care, existing resources were leveraged with about $250,000 of VA T21 funds (adding both a full-time geriatric nurse practitioner and a psychology technician to the multidisciplinary team) to design and implement the novel DEMO (Dementia Evaluation, Management and Outreach) program. This program aimed to (1) extend dementia evaluations to regional community-based outpatient clinics (CBOCs) that serve veterans in outlying regions; and (2) improve the management and the follow-up that these veterans receive, with a focus on containing costs, while improving both the quality of and veterans’ (and their families’) satisfaction with health care.
Methods
Dementia evaluations were conducted by a geriatric nurse practitioner and psychology technician teamlet at the CBOCs. In addition to neuropsychological testing, medical records were reviewed, caregivers were interviewed, and the patients were examined. The data were then brought back to the full BVAMC Geriatrics/Dementia Clinic multidisciplinary team for discussion. The team reached a consensus diagnosis and then made a comprehensive plan for the further evaluation and management of these complex patients. The plan was entered into the Computerized Patient Record System and communicated to the patient and caregiver during a follow-up CBOC visit.
The teamlet frequently provided informal education during CBOC visits in addition to formal lectures given by experts from the BVAMC and the University of Maryland. The DEMO program was introduced to providers at the CBOCs by e-mail with follow-up information sessions provided on site.
Rather than having patients simply return to their CBOC primary care providers (PCPs) and exposing patients to the risks of poor communication/coordination of care, services were expanded to include regular phone follow-up calls with case management services that augmented those of their PCPs. The goal was to improve outcomes for these patients and provide alternatives to institutionalization.
Standardized instruments were used to gauge patient and caregiver satisfaction, obtain cost data from the VA and the Centers for Medicare & Medicaid Services, and medication data from the Pharmacy Benefits files.
The institutional review board provided approval to collect data on participants to assess the program’s clinical and economic impacts. Since all patients were suspected to have dementia, the informed consent procedures included additional protections. The patient’s understanding of the pertinent information related to participation in the study was assessed to help ensure that participants with dementia truly understood the conditions to which they were consenting. If the potential participant could not provide informed consent, it was obtained from a surrogate with durable power of attorney (the person recognized by Maryland law as the substitute decision maker or the veteran’s legal guardian). Consent was assessed on an ongoing basis regardless of the patient’s capacity to give informed consent, and those willing to have their data collected were enrolled in a “research” arm. These participants were compared with veterans in the dementia clinic during the enrollment period but who did not consent to participate in the research arm, controlling for sociodemographic characteristics and prior health care utilization.