Interventions to Improve Quality of Care: The Kaiser Permanente"Alzheimer's Association Dementia Care Project

Published Online: August 01, 2004
Debra L. Cherry, PhD; Barbara G. Vickrey, MD, MPH; Lenore Schwankovsky, PhD; Eizabeth Heck, LCSW; Michelle Plauch??, MA; and Ralph Yep, MD

Objective: To improve quality of dementia care in a Kaiser Permanente service area through rigorous dissemination of practice guidelines and social worker support for physicians and patients.

Study Design: Pre-post design with practice behavior change assessed by medical record review, and provider and caregiver satisfaction with care assessed by surveys.

Methods: A diagnostic guideline and later a management guideline were adopted for use by Kaiser Permanente physicians in metropolitan Los Angeles. Physicians received training based on the guidelines, and social workers provided ancillary support. Eighty-three community-dwelling dementia patients and their caregivers were referred to the project by primary care physicians and then were assessed and followed by social workers. Data were abstracted from medical records to determine whether these interventions led to improved quality of care as indicated by adherence to key care processes derived from the adopted dementia guidelines. Chi-square and t tests were applied to compare guideline adherence and satisfaction rates before and after the interventions.

Results: Compared with baseline, higher rates of provider and caregiver satisfaction with Kaiser's system of dementia care were found at the postintervention follow-up. There also were significantly higher rates of adherence to several practice guideline–based quality measures: assessment of cognitive status; referrals to the Alzheimer's Association; and assessments of activities of daily living, decision-making capacity, depression, and wandering risk.

Conclusion: Quality of primary care for people with dementia can be improved through guideline implementation with care management support by social workers.

(Am J Manag Care. 2004;10:553-560)

Healthcare organizations are being challenged to care for the growing number of older adults with chronic health conditions. Dementing diseases, such as Alzheimer's disease, vascular dementia, and other associated disorders, present particular challenges because there are strong social and behavioral components to disease management. Physicians play a central role in assessment, diagnosis, and treatment; but much of the management for noninstitutionalized individuals is done by families with the support of social work care managers and community resource organizations. Furthermore, primary care physicians are daily faced with a broad range of disorders and are challenged by dementia patients, who may compensate for cognitive losses with retained social skills during the brief office visit.

Research suggests that Alzheimer's disease is neither well recognized nor systematically diagnosed.1-3 According to Boise and colleagues,1 physicians diagnose as few as 50% of dementia cases. Focus groups of primary care physicians from 3 geographic areas found significant barriers to the recognition and formal diagnosis of dementia. Physicians reported difficulty in recognizing possible dementia. Many reported that they relied on families to bring the disease to their attention. There also was a prevalent viewpoint that a formal diagnostic evaluation (including a comprehensive clinical history and mental status examination, laboratory referrals to rule out treatable conditions, and other procedures) is not always necessary.

Yet delay in diagnosis also means delay in treatment. The last 10 years have seen approval of several medications effective in slowing progression of Alzheimer's disease, the most common type of dementia in people with mild or moderate cognitive impairment.4 Furthermore, people with undiagnosed dementia and their families are less likely to gain access to supportive services that can ameliorate caregiver burden and perhaps delay institutionalization.5,6

Clinical practice guidelines have been developed and promoted as tools for improving dementia care.7-11 However, practitioners often are not familiar with these guidelines; and even when disseminated broadly, the guidelines are not implemented uniformly.3,12

Managed care organizations offer some unique possibilities for quality improvement in dementia care. They provide the communication lines for dissemination of guidelines. Their accreditation is dependent on adoption and implementation of guidelines-based quality improvement projects.13 Capitated payments can be used creatively to bring in the services of less expensive professionals that may reduce costs or hold them steady while improving quality. A number of pilot projects have been initiated to improve care for people with dementia in managed care settings 14; one such project, involving a large managed care plan in Los Angeles, is described here.

METHODOLOGY

Overview of Project and Description of Intervention

In 1995, Kaiser Permanente's Metropolitan Los Angeles Service Area entered into a partnership with the Alzheimer's Association of Los Angeles to assess and improve the quality of care provided to people with dementia. The Metropolitan Los Angeles Service Area of Kaiser Permanente serves a densely urban and ethnically diverse region. It includes 2 major medical centers and several satellite clinics. Based on extrapolated demographic estimates,15 up to 5000 people with dementia may be served by Kaiser Permanente in this region.

The goal of the Dementia Care Project was to improve the quality of care for people with dementia while increasing provider and consumer satisfaction. The study used a longitudinal preintervention/postintervention design, with evaluation data collected by medical record review, caregiver interview, and provider survey. A consensus-based diagnostic practice guideline was developed by a multidisciplinary panel of Kaiser Permanente practitioners and representatives of the Alzheimer's Association's Medical and Scientific Advisory Board. The disciplines of neurology, psychiatry, geriatrics, family practice, psychology, and social work all were represented in the development group. This guideline sought to improve consistency in the diagnostic assessments done at Kaiser Permanente in this region. The project later adopted a management guideline published by Cummings et al.10 To implement these guidelines as part of the Dementia Care Project, the following steps were taken:

  • Promotion by Kaiser Permanente's clinical leadership through letters to providers and presentations at meetings.
  • Broad dissemination of a laminated pocket version of the diagnostic guideline to all primary care physicians in this service area.
  • Annual in-service training for primary care providers that was notable for its inclusion of physician leaders and caregivers as speakers, as well as the participation of a theater troupe that enacted a physician visit and the administration of a mental status examination. The theater troupe was used to increase physician empathy for presenting families. It also was assumed that the novelty of this form of teaching would enhance learning.
  • Broad dissemination of a provider "tool kit" that contained the 2 guidelines and a variety of forms and tests of mental status and depression to support physicians as they followed guideline recommendations.

The Figure and Table 1 present outlines of the diagnostic and management guidelines used by the Dementia Care Project.

Figure

Figure

The Dementia Care Project relied heavily on social work care managers to support this guideline based quality initiative. Two full-time professionals were trained by the Alzheimer's Association with a 24-hour intensive course followed by 7 months of mentoring via case conferences. Patients were referred to the social workers by their primary care physicians. The social work care managers provided a range of services in support of physicians, including administration of mental status exams, follow-up with families on the psychosocial aspects of care, home visits, intervention with families regarding behavior management issues, and facilitation of connection to physicians for treatment of comorbid conditions. The care managers also provided guideline recommended services for family caregivers, including assessments of patients, linkage to services within Kaiser Permanente and in the community, caregiver support groups, family education, and ongoing care management.

Sample

In order to participate in the Dementia Care Project, the person with dementia needed to have a primary care physician in the designated Kaiser Permanente service area, have a guideline-based dementia diagnosis, dwell in the community (not in an institution), and have an involved, nonpaid caregiver. Participants also needed to be referred for participation by their primary care physicians. Data were collected on 83 persons with dementia and their caregivers. The dementia patients ranged in age from 63 to 93 years (mean age = 80 years). They were 52% male and ethnically diverse (55% African American, 21% Caucasian, 3% Latino, 1% Asian, and 19% other or not specified). This ethnic diversity reflects the membership of Kaiser Permanente in this geographic region. Initial Folstein Mini-Mental Status Examination scores16 recorded after the program intervention began were available for more than 90% of the patients and ranged from 2 to 29 with a mean score of 17. Of the 83 participating caregivers, 63% were spouses; 16%, daughters; 11%, sons; and 10%, other. Their mean age was 66 years. The ethnic breakdown of caregivers was 52% African American, 23% Caucasian, 4% Latino, 4% Asian, 1% Native American, and 16% other or not specified.

Study Outcome Variables

The study was primarily focused on improving the quality of care for people with dementia in this targeted region. The following indicators of improved quality were drawn from the practice guidelines:

  • Conducting a cognitive assessment with the Folstein Mini-Mental Status Examination.16
  • Obtaining laboratory tests (B12, Venereal Disease Research Laboratory/rapid plasma reagin [test for syphilis], thyroid-stimulating hormone, complete blood count, and selected blood chemistries).
  • Referral to the Alzheimer's Association and to the Safe Return Program (for wandering risk) of the Alzheimer's Association.
  • Conducting assessments that included activities of daily living, decision-making capacity, depression, and wandering risk.

These care processes were selected as study outcomes in part because they were guidelines targeted by the intervention. In addition, they have been identified and used with some frequency in studies of the quality of care for dementia.17 It was predicted that each of these practices would increase as a result of project participation.

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