A Natural Experiment Created by Pandemic Restriction: Comparing In-Person, Hybrid, & Teletherapy Formats

The FL-REACH intervention for families in early stage post-dementia diagnosis was originally adapted from the REACH II program for use in an outpatient clinic. Pandemic restrictions forced an adaptation to a teletherapy format. The timing of changes allowed comparison of caregivers who participated in clinic (n=10), switched modalities mid-treatment (n=7), and participated as teletherapy (n=14). Groups were similar in age range, gender, and relationship, with both spouses and adult children participating. Participants in the fully online group were more likely than others to have high school or trade school education than to have graduated from college. All participants in the in-person and hybrid groups had incomes over $40,000/year, while 36% of the online sample had less household income, were more likely to be Hispanic-identifying (43% versus 6%), and had higher burden scores (M=41.43 versus M=32.56 in person, M=29.86 hybrid) and lower preparedness scores (M=19.86 versus M=22.90 in person, M=28.14 hybrid) at baseline (p<.05). The intervention proceeded with the same intervention dosage (8 hours total), and outcomes were essentially comparable, with all groups showing statistically significant improvement on measures of preparedness, burden, and risk. While in-person intervention helped strengthen relationships with the medical team, inclusion of family via telehealth provided opportunity for a more culturally responsive and inclusive engagement, although there remain questions regarding reasons for differences at baseline. Identification of differences in key outcomes for direct comparisons between in-person, hybrid, and teletherapy interventions are limited in the evidence base, making this a unique study at an important moment in time.

User Interface and User Experience Testing of an Online Translation of the REACH II Intervention: GamePlan4Care

GamePlan4Care (GP4C) is a web-based adaptation of the Resources for Enhancing Alzheimer’s Caregiver Health II (REACH II) caregiver intervention, redesigned and reformatted for online delivery. The goal of GP4C is to create an online family caregiver support platform that facilitates self-directed exposure to evidence-based skills-training and support for dementia caregivers. This approach of utilizing technology enhanced with live support has the potential for scalability and sustainability. In preparation for an ongoing randomized clinical trial, the GP4C platform underwent industry standard user interface/user experience (UI/UX) testing with dementia caregivers as part of an iterative design process. Testing of caregiver’s reaction to technical and content-related aspects of the system was conducted with 31 caregivers. The thematic analysis revealed three themes for technical aspects (logical flow, suggestions on features, innovative resource) and two themes for content aspects (satisfaction and engagement). We will discuss technical and content modifications resulting from UI/UX.

GAMEPLAN4CARE: AN ONLINE TRANSLATION OF REACH II REFINED THROUGH EARLY STAKEHOLDER USABILITY TESTING

Despite a number of evidences on the implementation of multicomponent education and support programs to improve the lives of dementia caregivers, there is still a need to adapt these interventions to various implementation settings and preferences of a new generation of caregivers. In this study, we present the development and usability testing of a dementia caregiver support program, GamePlan4Care (GP4C), an online translation of the Resources for Enhancing Alzheimer’s Caregiver Health II (REACH II) intervention. The goal of the GP4C is to create an online family caregiver support system that would facilitate delivery of an evidence-based skills-training and support for dementia caregivers with the potential of both scalability and sustainability. GP4C includes the full breadth of REACH II education and skill-building materials, delivered within an automated, online platform with integrated support from a Dementia Care Specialist via telephone/video conferencing. Dementia caregivers, community agency staff, and other experts are involved in usability testing to ensure acceptability of this new approach to intervention delivery. The software development is completed and usability testing is currently underway. The feasibility and success of this new modality of intervention delivery will be made possible by an innovative intervention design supported by appropriate technical and content elements. We will also present the strategies employed to adapt the intervention to an online platform capable of supporting caregiver self-directed exposure to therapeutic content, the results of usability testing with approximately 32 caregivers, and feedback from other external stakeholders on the feasibility of this approach.

FRAILTY IN REACH II CAREGIVERS: A SECONDARY DATA ANALYSIS

Frailty, a reduction in reserve capacity in people who are otherwise considered healthy, affects between 9 and 13% of adults who are older. Frailty is a poorly understood syndrome; however, frailty is correlated with negative CV procedure outcomes, falls and institutionalization. Little is known about frailty in caregivers. A secondary data analysis was conducted using the REACH II publicly available dataset and the Groningen Frailty Index (GFI). At consent two percent of REACH II caregivers had difficulty going to the toilet while 11% had difficulty walking outdoors. More than 1/3 had hearing and vision losses. 75% felt sad or dejected. 82% were taking more than 4 medications. Based on their calculated GFI, between 61% and 64% of the REACH II caregivers were frail. Frail caregivers and their care recipient were less likely to go to the emergency department (-0.110 coefficient; p = 0.004 95% CI -0.184 -0.035) and were less likely to be hospitalized overnight during the past 6 months (-0.121 coefficient; p=0.004; 95% CI -0.203 -0.040). Frailty is an under-recognized syndrome in caregivers. Little is known about the impact of frailty on the caregiving dyad; however, ED utilization and hospitalization was decreased in these caregivers and their care recipients. This decrease may imply a delay in seeking care; and, in fact, lead to worse health outcomes for the dyad. With the aging of Baby Boomers and the continued dependence for long term care delivered by unpaid caregivers, implementation of programs to prevent and treat frailty in caregivers is essential.

Evaluation of REACH-TX: A Community-Based Approach to the REACH II Intervention

Background and Objectives Family caregiving interventions have been proven efficacious at reducing dementia caregiver’s stress and burden, yet translation of evidence-based interventions into community-based support service programs requires modification to the original intervention protocol. In collaboration with community partners, the REACH-TX program was developed based on the REACH II (Resources for Enhancing Alzheimer’s Caregiver Health) intervention. REACH-TX maintains the integrity of the multicomponent skill-based REACH II intervention but requires significantly fewer therapeutic contacts between the family caregiver and the dementia care specialist. This study presents an evaluation of REACH-TX implemented by the Alzheimer’s Association North Central Texas Chapter. Research Design and Methods REACH-TX was provided to 1,522 caregivers between November 2011 and December 2017. The number of therapeutic contacts scheduled for caregivers was determined by the Risk Appraisal Measure (RAM) and ranged from 1 to 23. The rate of follow-up data on outcome measures collected was 59.0% (n = 898). All five domains of the REACH II quality-of-life measure (burden, depression, social support, self-care, and problem behaviors) were assessed at baseline and at 6 months. Caregivers (n = 53) participating in the program more than once allowed us to investigate the long-term impact of the first exposure to REACH-TX and the value of repeating the program. Generalized linear models were used to assess changes in quality of life after adjusting for covariates. Results Caregivers who completed the program showed significant improvements from baseline to 6 months on all five domains of quality of life, as evidenced by the follow-up data. Furthermore, caregivers who enrolled a second time in REACH-TX showed significant improvement in burden and social support scores. Discussion and Implications This evaluation of REACH-TX suggests that REACH II evidence-based intervention can be translated into a valuable and sustainable community-based service for family caregivers. Additional translational research is needed to overcome the challenges of conducting standardized outcome assessments of caregiving services.

Measuring Treatment Fidelity: From Research to Implementation

Background: Treatment fidelity is commonly assessed in research trials because greater fidelity helps later replication in practice and is generally associated with better outcomes. However, implementations after initial research may not be as faithful to the original protocol, leading to unsuccessful replication. Methods: Fidelity methods of the Resources for Enhancing All Caregivers Health in the VA (REACH VA) dementia caregiving clinical implementation were examined with comparisons to those of the Resources for Enhancing Alzheimer’s Caregivers Health (REACH II) randomized clinical trial. The NIH treatment fidelity conceptual framework was used, which includes design, provider training, delivery, receipt, and enactment. To translate these concepts into practice, for each REACH VA session, core activities that measured delivery, receipt, and enactment were identified. These core activities were then examined for a sample of 293 caregivers of veterans with dementia who received the REACH intervention from June 2012 to September 2014. Results: Methods to assess fidelity were not as extensive for REACH VA, compared to REACH II. However, fidelity methods were present in all five framework aspects. Overall completion of core items for delivery and receipt/enactment was 92%. Completion of core items declined as sessions continued, with delivery declining from 97.2% of items completed for Session 1 to 85.7% for Session 4; receipt/enactment declined from 97.3% to 88.4%. Conclusions: Consistent attention to maintaining treatment fidelity may explain why caregiver outcomes are similar in both the original REACH II randomized clinical trial and in the REACH VA implementation. The process followed to assess REACH fidelity is applicable to other evidence-based interventions that have been or are going to be implemented into practice. Fidelity assessment need not be continually re-invented, nor must it be elaborate. Critical components of an intervention as developed and practiced can and should be used to assess fidelity seamlessly. The interplay between how an intervention fits into the organization, ongoing assessment of its practitioners, and its effect on those participating in it should be seamless. In this way, fidelity assessment is not an add-on or burdensome for busy providers, supervisors, and organizations. Trial Registration: ClinicalTrials.gov: NCT00177489, Registered 12 September 2005, retrospectively registered. Keywords: Treatment fidelity; translational research, reproducibility; reliability; validity.