A person with dementia of the Alzheimer's type will live an average of four to eight years, and as long as 20 years, after the onset of symptoms. During this illness trajectory, the overwhelming majority of the person's care is provided by family and friends, who serve as a safety net for the person with dementia. A Home Safety Toolkit has been shown to improve safety for Veterans with dementia and decrease caregiver strain. The purpose of this project is to study the processes necessary to make a Home Safety Toolkit (HST) for Veterans with dementia of the Alzheimer's type or a related disorder accessible to these patients and their caregivers; and to gather additional information about the effectiveness of the HST when implemented in Veteran Health Administration (VHA) primary care clinics.
The objectives are to: 1) Conduct a diagnostic analysis of the current processes by which Veterans receive home safety items, and identify the modifications necessary in order to provide the HST to Veterans with dementia. 2) Design and implement a tiered menu of implementation strategies to facilitate adoption of the Home Safety Toolkit. 3) Use the RE-AIM evaluation framework to assess the overall success of HST implementation: extent of Reach, Effectiveness, Adoption, Implementation and Maintenance.
The project is a Type 3 Implementation -Effectiveness Hybrid Research Design.
Two Veterans Health Administration Networks, one in the Northeast and one in the Mid-Atlantic region are participating sites. Phase 1 consists of formative evaluations using semi-structured interviews with key staff informants (MD, NP, RN and OTR, Prosthetics and Sensory Aids managers) who have had an experience assessing, prescribing, and/or providing home safety items for a Veteran in the past 6 months. In addition, patients' and caregivers' perceptions of the facilitators of and barriers to successful acquisition and use of home safety items will be explored. Phase 2 will evaluate the implementation strategies that are successful to provide the HST to Veterans with dementia and their primary caregivers. Themes will be categorized based upon the Context and Evidence components of the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Complementary quantitative data from the Organizational Readiness to Change Assessment tool will be analyzed and used to both inform Facilitation strategies and to identify patterns of facilitation activities and other implementation interventions. A tiered approach to implementation will then be employed, ranging from more general approaches to more specific activities, e.g. Email broadcast to Network Email groups that include stakeholders who are caring for Veterans with dementia; use of a chart "flag" or computerized clinical reminder that a Veteran with an ICD-9/10 diagnosis of dementia may be eligible for a HST; audit of HSTs provided to Veterans and feedback to providers.
There is no change in the methods except that we have decided not to survey the staff using the ORCA because of the minimal expected returns for the effort . We are focusing our efforts on the implementation of the toolkit to the Veteran dyads.
Qualitative interviews elucidating the aspects of the process were addressed through consultation with the VERC (Veterans Engineering Resource Center). Where possible, variation in the process strove for consistency.
Recruitment and data collection for Aim 1 are completed and qualitative data analysis is being finalized. Implementation strategies and small tests of change are in process. We identified insurmountable barriers to VA-wide implementation of the HST related to challenges to the ordering of equipment deemed not durable medical equipment.
The evidence-based Home Safety Toolkit for Dementia was shown to have significant outcomes in reducing family caregiver strain, reducing Veteran risky behaviors and accidents, and increasing family caregiver home safety modifications and self-efficacy. This implementation study demonstrated significant barriers to implementation of the HST across VHA through primary care providers. However, by refocusing our efforts on disseminating the companion workbook as a stand-alone item with reference to the home safety items originally included in the toolkit, family caregivers will be informed of strategies for keeping people with dementia safer at home. We have developed a PowerPoint presentation about the workbook to inform clinical care providers about the workbook and how to educate family caregivers of people with dementia about its use. Wide dissemination of this workbook, even without the items in the toolkit, will inform caregivers of ways to keep people with dementia safer at home.
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