Outcomes of an Embedded Resource and Education Program for Patients and Families With Memory Loss
aging, elderly, geriatrics, communication, patients, providers, ambulatory/outpatient care, complex disease management, multiple chronic conditions, chronic disease
Background: Patients with a new diagnosis of memory loss or dementia and their families typically wait 2 years before connecting to and utilizing community resources. Lack of education and support frequently results in crisis-driven care and hospitalization for patients, as well as care-related strain, depression and other negative outcomes for caregivers. Memory PREP (Patient Resource & Education Program) is a 4-month embedded program for patients with dementia and their families that involves meeting with a social worker in person or by phone to cover a curriculum of disease education, support and connection to community resources.
Methods: Patients and their care partners (dyads, n = 90) were recruited from two sources: physician referral from HealthPartners Center for Memory & Aging, and through a mailing to patients throughout our care delivery system who were identified to have a new diagnosis code of dementia in their electronic health record. The intervention consisted of 5 encounters with a masters-level, specialty-trained social worker and randomization to either phone-only or 2 in-person plus 3 phone visits. The intervention curriculum was similar and ad hoc phone support was available to both groups. Outcomes included disease knowledge, mood, social support, health, stress, caregiver burden and quality of life and were evaluated at baseline, after program completion (4 months) and at 8 months. Changes from baseline were assessed using paired t-tests; ANOVA was used for comparisons.
Results: The Memory PREP program significantly increased care partner’s knowledge of Alzheimer’s disease, emotional support and completion of care planning (eg, power of attorney, driving and safety plans, and use of support groups). The program was equally effective when administered by phone as it was when administered in-person. The program received strong positive feedback from participants, especially care partners and family members; 93% of participants were likely to recommend the program to others.
Conclusion: Health care providers are struggling to meet the needs of patients and families facing dementia. Education and support are an important part of the care plan that is often outsourced to community partners. This embedded program led to increased knowledge, feelings of support, and completion of important safety and planning actions. Delivery of this program by phone may be a useful option to reduce barriers of access.
Hanson L, Forsberg A, Thomas A, Crow J, Haley-Franklin H, Barclay T. Outcomes of an embedded resource and education program for patients and families with memory loss. J Patient Cent Res Rev. 2017;4:144-5.