Research Brief

Dementia is a common problem in older individuals, and very prevalent in those over 85. But care provided for dementia is poor. Assessing Care of Vulnerable Elders-2 (ACOVE-2), a RAND Health project focused on redesigning primary care practices in order to improve care for elders, was successful in enhancing care for falls and urinary incontinence but not for dementia. Analysis of program results showed that physicians performed better on medical components (e.g., ordering tests) than on counseling and education for dementia patients and their caregivers. Alzheimer's Association chapters provide these kinds of support services, but the medical community and Alzheimer's Association chapters rarely communicate or collaborate.

To address this need, RAND researchers strengthened ACOVE-2 in three ways: Participating primary care physicians were given feedback about their baseline performance, focus groups were conducted to gain provider perspective on unmet needs in managing dementia patients, and the project team worked directly with practices to customize the intervention in order to meet these needs and to improve quality of care. The third component included establishing referral links to local Alzheimer's Association chapters to enhance patient and family education and community services. The improved intervention was pilot tested in two community-based physician practices and evaluated.

Key findings from the evaluation include the following:

  • Overall quality of care improved: The percentage of quality indicators that were met rose from 38 percent to 46 percent.
  • Assessment of functional status, discussion of the risks and benefits of antipsychotics, and counseling of caregivers significantly improved.
  • Quality indicators for cognitive assessment, review of medications, and neurological examinations did not improve.

Before the program, no patients at either site had been referred to the Alzheimer's Association; after the intervention, 17 percent had been referred. Quality scores for the referred patients were higher, and they were more likely to receive counseling about driving, caregiver counseling, and specification of a surrogate decisionmaker.

Results of this pilot program suggest that a quality improvement program specifically focused on dementia care, when coupled with strong linkages to local Alzheimer's Association chapters, is a promising approach to improving the quality of dementia care.

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