In the survey, 98% of caregivers and patients felt that the program helped them deal more effectively with their problems, 97% would recommend the program to a friend in need of similar help, and 100% would come back if they were to seek help again. In keeping with DEMO’s initial aim of increasing access, there was favorable feedback on the ability to get in and be seen and convenience of location. In addition, referring providers universally expressed satisfaction with the referral process (referrals increased linearly); timeliness of scheduling; usefulness of the recommendations; and they planned on continuing to refer patients.
Although there was great variability, controlling for age and prior utilization, veterans in DEMO had statistically significant (all P < .05) fewer ED and specialty care visits and more mental health care clinic visits 183 to 365 daysafter referral dates compared with those in the nonconsented group. Veterans in the consented group also were less likely to use inpatient care than were veterans in the nonconsented group 183 to 365 days after referral dates. These trends were similarly reflected after controlling for age and prior utilization as well as when examining health care costs (data not shown). Nonetheless, DEMO did not seem to have any effect on overall inpatient bed days, primary/home-based care visits, or total costs. In fact, utilization of mental health care resources increased (Figures 1, 2, and 3).
Discussion
Cognitive issues in patients within the general population are common, and the patients cared for by the VA are no exception. Dementia is more common in rural compared with urban areas, and those living in more remote locations have reduced access to specialized evaluation, management, and support services.2 The authors describe a novel program that dramatically increased patient access, bringing the normally tertiary referral services to geographically remote CBOCs at a minimal investment. These services were well received by patients, caregivers, and PCPs. As anticipated, patients and their caregivers especially appreciated the ease and convenience of access. Considering the already significant burden(s) borne every day by those caring for patients with dementia, the benefit of this approach is evident.
Clinicians often feel uncomfortable in evaluating and managing patients with cognitive deficits. Nonetheless, the role of specialized clinics in diagnosing dementia has been demonstrated previously, and the present results are in agreement with previous studies.3 The novelty here is the provision of specialized care usually found only in large, academic medical centers to local CBOCs. By bringing specialized services to geographically isolated patients, the DEMO program was able to increase both access and utilization. Furthermore, providing coordination and ongoing, focused follow-up provided increases in satisfaction and efficiency.
An additional benefit of this approach is the opportunity for PCP education. The authors even found anecdotal reductions in ED usage as well as acute hospitalization and long-term placement—although it was not a statistical significant difference. The relatively high use of mental health care services in this population is in line with previous reports in similar populations, and greater utilization of mental health care services may be one explanation why overall costs did not differ between the 2 groups.4 Nonetheless, this intimates that such a program may yield savings over a longer term, as has been demonstrated in patients with a variety of other psychiatric diagnoses cared for in the community rather than in institutions.5,6
The prevalence of dementia and its associated costs are nearly $50,000 per year per person—suggesting a total cost in the hundreds of billions of dollars.7 Similarly, the importance of caregiver support (including psychosocial interventions, such as the one piloted here) has been demonstrated in a variety of settings (even without improvement in caregiver burden itself).8
There were a number of challenges in the rollout and delivery of DEMO. Although CBOC PCPs were initially somewhat uncertain of the benefit of this approach and concerned about the space requirements, referrals rapidly and dramatically increased, and the DEMO teamlet became enmeshed with CBOC staff. Similarly, potential participants and their caregivers sometimes were leery to involve others in their care. Both the CBOC PCPs and caregivers came to depend more on DEMO staff, and the DEMO staff members frequently were the first ones to be called (at times for issues unrelated to dementia).
Unfortunately, DEMO was underresourced to provide either real-time feedback true or first responder services. Misunderstandings concerning this were an early challenge to PCP acceptance. However, the longitudinal presence and close working relationships of the DEMO teamlet in each CBOC allowed their use as an adjunct to primary care, and increased the efficacy of both.