Families provide the majority of care to individuals with dementia and become at risk themselves for depression, poor health, diminished quality of life, and mortality (Schulz & Beach, 1999
). Despite proliferation of proven interventions, families continue to be underserved or receive services that are not evidence based (Brodaty, Green, & Koschera, 2003
; Centers for Disease Control and Prevention, 2008
; Sörensen, Pinquart, & Duberstein, 2002
). Dementia caregiver interventions are not fully integrated into community-based services, and fewer still are evaluated for sustainability within existing funding streams (Burgio et al., 2009
Translation of proven caregiver programs primarily train care managers or social workers for delivery through the aging service network (Burgio et al., 2009
), Veterans Association (Nichols, Martindale-Adams, Burns, Graney, & Zuber, submitted
), or hospital discharge (Stevens, Lancer, Smith, Allen, & McGhee, 2009
). Evidence-based programs have not been translated for delivery in homecare nor involved training health professionals with routine contact with dementia patients and their families.
Furthermore, translational efforts are supported through government agency (Administration on Aging) and foundation (Rosalynn Carter Institute/Johnson & Johnson) grants. Unclear is whether existing reimbursement mechanisms, such as Medicare, support delivery of programs. Although the Medicare Alzheimer’s Disease Demonstration Evaluation involved care management as an extended Medicare benefit, few differences in caregiver outcomes and only at certain participating sites were found (Newcomer, Yordi, DuNah, Fox, & Wilkinson, 1999
). No further involvement of Medicare in caregiver programming has been evaluated.
This article reports on the translation of the Environmental Skill-building Program (ESP) for delivery by occupational therapists (OTs) in private practice, Fox Rehabilitation, which provides house calls using Medicare Part B reimbursement.
Fox, an independently owned private practice, provides physical therapy, occupational therapy, and speech–language pathology services to older adults in homes, assisted living, or adult medical day centers in five mid-Atlantic states. Fox employs more than 350 clinicians of whom 120 are OTs. Therapists provide an average of 2,800 visits to approximately 930 patients weekly. Approximately 40% of individuals living at home referred for Fox's services have significant cognitive impairment. Although therapists provide basic caregiver education as standard care, a systematic or proven approach to identify and address caregiver concerns is not used.
Previous research shows that patient functional decline, caregiver distress, and physical strain are strong predictors of nursing home placement (Spillman & Long, 2009
). Thus, training therapists in a proven program to help distressed caregivers improve skills to manage patient-related concerns, may enhance caregiver well-being, and quality of care provided to patients.
This is the first translational effort to our knowledge that involves integrating a proven caregiver intervention into a large private homecare practice as part of routine therapeutic services provided to dementia patients through Medicare Part B.
Medicare, a major public resource for long-term care reimbursement, provides part-time skilled homecare including physical, speech, and occupational therapy to participants in outpatient clinics or homes. Whereas Medicare Part A provides reimbursement for traditional home health services and requires participants to be home bound, with Part B, a physician referral is required and patients with functional decline and/or safety concerns qualify for this service which can occur in outpatient settings or the home (Centers for Medicare and Medicaid Services [CMS], 2008
). For Medicare Part B, referral by a physician to occupational therapy may occur after an acute episode, such as a hospitalization or fall or in the absence of an acute episode, to address functional decline with progression of a chronic condition. Referral to occupational therapy, and successful reimbursement, is for the impairment, functional limitation, or disability of the patient and not specifically to treat the diagnosis of dementia. Dementia is a chronic progressively deteriorating disease in which management of functional decline is critical. Although Medicare Part B currently does not have a separate Current Procedural Terminology code specifically for “caregiver training,” caregiver training is allowed and reimbursed when it is directly related to supporting the patient’s functional tasks or performance of instrumental and basic activities of daily living. As stated in Medicare Benefit Policy Manual chapter 15, rehabilitative services may include family training to augment rehabilitative treatment. According to Medicare policy, education of family should be ongoing through treatment and instructions may have to be modified intermittently if the patient’s status changes (CMS, 2010
Referral to occupational therapy services was not made for the ESP caregiver intervention specifically, as ESP was not provided as a separate program or intervention. Rather, ESP was integrated into existing OT patient treatment plans for patients with dementia and overwhelmed caregivers.
Approximately 5.1% of community-dwelling Medicare beneficiaries have a dementia diagnosis, although this estimate is low given that dementia is not typically the primary diagnosis for referrals. In 2005, Medicare spent $91 billion on beneficiaries with dementias. This number is predicted to double to $189 billion by 2015 (Gruber-Baldini, Stuart, Zuckerman, Simoni-Wastila, & Miller, 2007
ESP, tested by the National Institutes of Health Resources to Enhance Alzheimer’s Caregivers Health (REACH I) and subsequent randomized trials, provides caregivers specific knowledge and skills to support daily function and manage neuropsychiatric behaviors of dementia patients, enhance home safety, and alleviate caregiver upset and care concerns (Gitlin, Corcoran, Winter, Boyce, & Hauck, 2001
; Gitlin et al., 2003
). ESP meets Medicare Part B reimbursement requirements as it links caregiver training to patient functional goals. Thus, there is potential to sustain delivery through this funding mechanism.
Prior to implementing ESP agency wide, we conducted a 2-year translational phase to evaluate proof of concept at one Fox location. Specifically, we sought to evaluate adequacy of a training program for therapists with full caseloads, whether ESP could be integrated with fidelity into standard patient care encounters, and reimbursed through Medicare Part B. This article describes the key translational activities, outcomes, and challenges and lessons learned.
To evaluate outcomes, we applied a public health framework, Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) that designates multiple criteria at the individual, agency, and societal levels to understand impact (Glasgow, 2002
; Glasgow & Emmons, 2007
). Application of this model involves understanding program “reach” (number of caregivers approached and enrolled); effectiveness (perceived benefits); adoption (training adequacy and number of therapists using program); implementation (fidelity); and maintenance (sustainability).