Caring for Older Adults and Caregivers at Home (COACH)
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Share PrintCOACH is a home based dementia care program that serves Veterans living with dementia and their caregivers residing within 50-mile radius from the medical centers or rural clinics. The goals are to improve Veterans and caregivers quality of life, reduce safety hazards, reduce caregiver burden, and delay nursing home placements. It operates with a geriatric interdisciplinary team that offers a holistic patient-centered and non-pharmacological approach integrating best evidence based practices. The core team, a social worker and a nurse, provide ongoing support and educational interventions via home visits, telephone, telehealth, groups, and educational series. The major areas of intervention include behavioral management, safety, caregiver stress, advance care planning, and dementia related functional concerns. The program is fully recognized as an Age-Friendly Health System Committed to Care Excellence.
Origin:
October 2012, Durham VA Medical Center
Adoptions:
4 successful
Awards and Recognition:
Rural Promising Practice, VHA Shark Tank Winner, Gold Status Practice
Partners:
Geriatrics and Extended Care
Recent Updates
Overview
The problem
COACH addresses all of these challenges using a holistic patient-centered care approach. See more
The solution
Files
- Publication at the Journal of Geriatrics Society - Preliminary Data from the Caring for Older Adults and Caregivers at Home (COACH) Program: A Care Coordination Program for Home-Based Dementia Care and Caregiver Support in a Veterans Affairs Medical Center JAGS publication - COACH Preliminary Data
The results
Files
- Poster presented at the American Geriatrics Society on reduction of agitated behaviors and reduction of caregivers negative reactions to those behaviors. COACH: Home-based Management of Behaviors in Dementia
- DYING AT HOME: DISPOSITIONS FOR VETERANS IN THE COACH PROGRAM AT THE END OF LIFE COACH: Caring for Older Adults and Caregivers at Home
Metrics
- Reduction on nursing home placement (NHP): COACH patients had 4% of NHP, control group had 7%.
- 41% of COACH patients died at home, only 13% of the general population with dementia on death certificate die at home.
- Caregivers reduced negative reactions to agitated behaviors by 34% after one year of interventions.
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Multimedia
Images
Above:
Disposition at End of Life: Dying at Home
Implementation
Timeline
-
1-3 Months
Present practice to facility leadership and stakeholders and secure buy-in and support -
1-3 Months
Secure program staff and resources and customize materials -
1-3 Months
Begin COACH training -
1-3 Months
Execute program/Enroll 1st Cohort
Departments
- Social work
- Geriatrics
- Administration
- Nursing services
Core Resources
Files
- COACH_One_Pager_Overview_v6.pdf COACH_One_Pager_Overview_v6.pdf
- COACH_One_Pager_Impact_v6.pdf COACH_One_Pager_Impact_v6.pdf
Risks and mitigations
| Risk | Mitigation |
|---|---|
| If the facility does not have the resources or funding required then it may slow down or hault implementation | Facilities have the option of applying for the VHA GEC Mentoring Partnership program which provides funding for up to 2 years, or the facility can develop a cost neutral approach for implementation utilizing current resource |
| No protected time for implementation for Champion in the first phase. | The facility may allow dedicated time to Champion to actively implementing COACH. |
About
Origin story
Original team
Judith Davagnino, LCSW, MSW, CSW-G
COACH Program Director, Durham VA Health Care System
Jack Twersky, MD
COACH Medical Director
Comment
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