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Caring for Older Adults and Caregivers at Home (COACH)

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COACH 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.

This innovation is emerging and worth watching as it is being assessed in early implementations. See more emerging innovations.

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

Tags:

Access to Care Age-Friendly Continuity of Care Coordinated Care Diversity, Equity, and Inclusion Geriatric Health Health Equity Home Health Rural Health Telehealth
Contact Team

Overview

Problem

The number of patients with dementia is rapidly growing every year along with the cost to patients, families, and facilities. Dementia causes an emotional, physical, and financial strain among those affected. Without specialty care and targeted resources, the behavioral symptoms experienced by patients with dementia are often inadequately addressed and const ... See more

Solution

COACH was designed to improve the quality of life for both patients with dementia and their caregivers, help veteran to remain living at home for as long as possible, and alleviate caregiver burden. With a multidisciplinary approach, the program offers support, education, skills building in dementia care, and assistance to obtain resources to both Veterans a ... See more

    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

Results

The program has demonstrated to increase Veterans' quality of life, reduce nursing home placements, reduce caregiver burden, and reduce safety hazards in their home environment.

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)

Statuses

AZ: Carl T. Hayden Veterans' Administration Medical Center (Phoenix, Arizona) KY: Robley Rex Department of Veterans Affairs Medical Center (Louisville) MO: Harry S. Truman Memorial Veterans' Hospital (Columbia, Missouri)
  • Started adoption on 10/2021.
VA: Richmond VA Medical Center (Richmond, Virginia)
  • Started adoption on 04/2018, ended on 09/2019.

There are no in-progress adoptions for this innovation.

There are no unsuccessful adoptions for this innovation.

Multimedia

Images

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

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.

Contact

Comment

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Email

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About

Origin story

The VA currently serves over 190,000 veterans with dementia with a significant associated cost. The main contributing risk factor for developing dementia is age, and the veteran aging population is growing rapidly. We anticipate many veterans with dementia care needs in the short term. Dementia causes an emotional, physical, and financial stress among affect ... The VA currently serves over 190,000 veterans with dementia with a significant associated cost. The main contributing risk factor for developing dementia is age, and the veteran aging population is growing rapidly. We anticipate many veterans with dementia care needs in the short term. Dementia causes an emotional, physical, and financial stress among affected individuals and their caregivers. Older adults have a strong preference to remain at home; nonetheless, the progressive frailty, high level of caregiver strain, and significant behavioral challenges lead to high level of institutionalization. Ambulatory care assessments are often difficult because of the travel involved, the stress, agitation and confusion the Veteran may experience outside of their home environment. The behavioral symptoms they experience are often inadequately addressed and they constitute the main predictor for nursing home placement. Veterans living in rural areas have even a more difficult time to access specialty care and resources. COACH, a home-based dementia care program that serves Veterans with dementia and their caregivers was developed to address these challenges.

Original team

Judith Davagnino, LCSW, MSW, CSW-G

COACH Program Director, Durham VA Health Care System

Jack Twersky, MD

COACH Medical Director

Search tags

Access to Care Age-Friendly Continuity of Care Coordinated Care Diversity, Equity, and Inclusion Geriatric Health Health Equity Home Health Rural Health Telehealth