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The Tailored Activity Program-VA (TAP-VA)
Share PrintThe Tailored Activity Program-VA (TAP-VA) is designed for Veterans with dementia and their caregivers. TAP-VA decreases dementia-related behavioral symptoms and caregiver burden by engaging the Veteran in activities that are individualized to their interests and abilities. TAP-VA provides VA clinicians with a protocol to 1) identify interests and abilities of Veterans living with dementia; 2) instruct caregivers on how to use selected, tailored activities as part of daily care routines; 3) provide disease education to caregivers; and 4) teach caregivers how to manage their own stress.
Origin:
January 2007, Drexel University and Thomas Jefferson University
Adoptions:
9 successful
Partners:
Health Services Research & Development, Quality Enhancement Research Initiative
Recent Updates
Overview
Problem
Most older adults wish to “age in place” by remaining in their home environment. For adults with dementia, behavioral symptoms such as agitation and aggression can interfere with this goal, and difficulty managing these symptoms is one of the strongest predictors of long-term institutional care. Family members provide 80% of care at home for patients wi
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Most older adults wish to “age in place” by remaining in their home environment. For adults with dementia, behavioral symptoms such as agitation and aggression can interfere with this goal, and difficulty managing these symptoms is one of the strongest predictors of long-term institutional care. Family members provide 80% of care at home for patients with dementia and are instrumental in delaying or avoiding institutional care. Thus, there is an urgent need to educate and support family caregivers in strategies to reduce challenging behaviors.
More than 250,000 enrolled Veterans have dementia nationally, including more than 10,000 in VISN 4. This number is expected to grow by more than 25% in the next 15 years. In VISN 4, the prevalence of long term nursing home use among patients with a diagnosis of dementia varies from 11% to more than 24% across VAMCs. The VA has been a leader in the development and dissemination of programs focusing on caregivers who are struggling to care for Veterans with dementia. However, these programs have focused on improving outcomes for caregivers during the later stages of the Veteran’s dementia, rather than optimizing function and reducing behavioral symptoms at earlier stages. Programs that take a proactive approach - targeting patient behavior and function – will allow the VA to provide services across the continuum of dementia severity and address needs proactively. See more
More than 250,000 enrolled Veterans have dementia nationally, including more than 10,000 in VISN 4. This number is expected to grow by more than 25% in the next 15 years. In VISN 4, the prevalence of long term nursing home use among patients with a diagnosis of dementia varies from 11% to more than 24% across VAMCs. The VA has been a leader in the development and dissemination of programs focusing on caregivers who are struggling to care for Veterans with dementia. However, these programs have focused on improving outcomes for caregivers during the later stages of the Veteran’s dementia, rather than optimizing function and reducing behavioral symptoms at earlier stages. Programs that take a proactive approach - targeting patient behavior and function – will allow the VA to provide services across the continuum of dementia severity and address needs proactively. See more
Solution
Dr. Laura Gitlin and colleagues developed TAP based on a conceptual model that views behavioral symptoms as resulting from a mismatch between an individual’s abilities/capacity and their environment. TAP is a 4-month, structured, manualized occupational therapy intervention that trains caregivers to deliver activities tailored to the care recipient’s in
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Dr. Laura Gitlin and colleagues developed TAP based on a conceptual model that views behavioral symptoms as resulting from a mismatch between an individual’s abilities/capacity and their environment. TAP is a 4-month, structured, manualized occupational therapy intervention that trains caregivers to deliver activities tailored to the care recipient’s interests and capabilities. For example, a Veteran who used to enjoy painting and is soothed by repetitive behaviors might be asked to paint a wooden box for 30 minutes. Since many challenging behaviors occur in response to an environment that is too demanding or under-stimulating, this approach helps to maximize the fit between an individual’s capabilities and environmental demands, promoting adaptive positive behaviors across multiple stages of dementia to proactively reduce challenging behaviors. In addition, TAP trains caregivers to be responsive to emergent and changing behavioral problems associated with dementia over time, increasing the caregivers’ skill set in managing these behaviors.
TAP’s effectiveness is supported by multiple trials, including an RCT of 160 dyads within the VA. Trials have demonstrated statistically and clinically significant reductions in functional dependency and disruptive behavioral symptom frequency. Compared to a control group, TAP caregivers spent an average of 3 fewer hours/day on caregiving tasks and 7 fewer hours/day “on duty,” and care recipients demonstrated fewer functional dependencies. Implementing TAP is expected to increase the ability of older adults with dementia to age in place aligning with national VHA priorities including: VHA modernization/Performance Plan, Whole Health, optimizing community care, and the MISSION Act.
TAP was adapted by the Safer Aging Through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) in VISN 4 to fit the VA-context. TAP-VA adaptations are based on collaborations with TAP developers, pre-implementation data collection, and VA organizational knowledge. See more
TAP’s effectiveness is supported by multiple trials, including an RCT of 160 dyads within the VA. Trials have demonstrated statistically and clinically significant reductions in functional dependency and disruptive behavioral symptom frequency. Compared to a control group, TAP caregivers spent an average of 3 fewer hours/day on caregiving tasks and 7 fewer hours/day “on duty,” and care recipients demonstrated fewer functional dependencies. Implementing TAP is expected to increase the ability of older adults with dementia to age in place aligning with national VHA priorities including: VHA modernization/Performance Plan, Whole Health, optimizing community care, and the MISSION Act.
TAP was adapted by the Safer Aging Through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) in VISN 4 to fit the VA-context. TAP-VA adaptations are based on collaborations with TAP developers, pre-implementation data collection, and VA organizational knowledge. See more
Videos
"Here's How TAP Works" by Drexel University Online
- TAP-VA One-Page Overview with Adaptations to Original TAP. TAP-VA One-Page Overview
Files
Results
TAP has been implemented in 12 countries, including the United States. Within the VA, TAP-VA has been implemented in eight VA Medical Centers and three community-based outpatient centers in VISN 4. There have been 89 VA clinicians that have completed the TAP training. The specialties of the clinicians trained include nurses (LPN, RN, NP), occupational t
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TAP has been implemented in 12 countries, including the United States. Within the VA, TAP-VA has been implemented in eight VA Medical Centers and three community-based outpatient centers in VISN 4. There have been 89 VA clinicians that have completed the TAP training. The specialties of the clinicians trained include nurses (LPN, RN, NP), occupational therapists (OT, OTA), physical therapists, providers (MD, DO), psychologists, recreational therapists, registered dieticians, and social workers. Most clinicians trained work in home-based primary care. However, some clinicians also work in specialty geriatric clinics and behavioral health. There have been 37 Veterans enrolled in TAP-VA across VISN 4 since January 2022.
See
more
Metrics
- Previous trials have demonstrated statistically and clinically significant reductions in functional dependence and disruptive behavioral symptoms.
- Previous trials have shown that caregivers spent an average of 3 fewer hours/day on caregiving tasks and 7 fewer hours/day "on duty".
- Previous trials have demonstrated that TAP saves $231 per month in caregiver’s hospital costs, $240 per month in paid caregiving time, and $1,299 per month in total healthcare costs (patient and caregiver).
- Efficacy results for TAP-VA implementation through QUERI are pending for the following: 1) reduction in caregiver burden (measured by the Shortform Zarit Burden Interview); 2) reduction in caregiver “time on duty” (time spent taking care of or monitoring Veteran with dementia); 3) reduction in caregiver distress (measured by the Perceived Change Index); 4) increase in caregiver well-being (measured by the Perceived Change Index); 5) caregiver’s perception of Veteran’s behavioral symptom changes over time (measured by the Perceived Change Index); 6) reduction in Veteran’s behavioral symptoms (measured by the Behavioral Symptoms Checklist); 7) decrease in the number of emergency department admissions compared to Veteran cohort that did not receive TAP intervention; 8) decrease in the number of hospitalizations compared to Veteran cohort that did not receive TAP intervention; 9) 90-day readmission rate compared to Veteran cohort that did not receive TAP intervention; and 10) number of nursing home admissions compared to Veteran cohort that did not receive TAP intervention.
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Implementation
Timeline
-
6 hours (over the course of 2-4 weeks)
Training:1) Email TAP@Drexel.edu to register for the TAP online training hosted by Drexel University; in the email, specify that you are a VA employee registering for the training through the SAGE QUERI2) Complete TAP's asynchronous, online modules hosted on Drexel University’s platform3) Schedule through the online training platform and attend a one-hour, virtual synchronous training with TAP developers4) Complete and submit TAP training checklist through the online training platform -
1 hour
Materials:1) Download (and print) TAP-VA implementation guide and TAP-VA session materials2) Order TAP resource books (Caregiver’s Guide to Dementia: Using Activities and Strategies to Prevent, Reduce and Manage Behavioral Symptoms and Allen’s Cognitive Levels: Meeting the Challenges of Client Focused Services, 2nd Edition) -
1 hour
CPRS:1) Request CAC upload of TAP-VA consult and note templates into VAMC’s CPRS system
Departments
- Social work
- Psychiatry
- Geriatrics
- Caregiver support
- Adaptive sports
- Nursing services
- Psychology
- Physical medicine and rehabilitation
- Physical therapy, occupational therapy and kinesiothology
- Recreation and creative arts therapy
- Whole health
Core Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
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PROCESSES |
|
TOOLS |
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Files
- Implementation Guide provides an overview of implementation procedures of TAP-VA. Includes: Adaptations, CPRS screenshots, Teams Channel link, and step-by-step implementation worksheet. TAP-VA Implementation Guide
- Session Checklists and Materials provides step-by-step checklists for each TAP-VA session and all materials necessary to complete the program. TAP-VA Session Checklists and Materials
- CAC CPRS Upload Instructions provides VAMC or VISN CACs with steps to upload the TAP-VA consult and note templates into a site's CPRS. TAP-VA CAC CPRS Upload Instructions
Links
- Link to purchase resource book for caregivers. A Caregiver's Guide to Dementia: Using Activities and Other Strategies to Prevent, Reduce and Manage Behavioral Symptoms.
- Link to purchase Allen's Cognitive Levels resource book for clinicians. Allen’s Cognitive Levels: Meeting the Challenges of Client Focused Services, 2nd Edition.
Optional Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
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Support Resources
| Resource type | Resource description |
|---|---|
TOOLS |
|
Links
- The goals of the TAP-VA Learning Collaboratives are to create a space for TAP-VA clinicians engage with and learn from learn from each other and to build a sustainable knowledge base for TAP-VA. TAP-VA Monthly Learning Collaborative
- The TAP-VA Teams channel is a forum to ask questions, collaborate, and share resources and ideas with other clinicians implementing TAP-VA. Please request to join group. Tailored Activity Program (TAP-VA) Teams Channel
Risks and mitigations
| Risk | Mitigation |
|---|---|
| TAP training commitment approximately 6 hours. Training consists of 5 hours of asynchronous, online modules, a 1-hour synchronous, virtual training with TAP developers, review of TAP training materials, and completion of a TAP case study | Clinicians should obtain approval to participate in training from supervisor and complete as time allows in their schedule. There is no timeframe for training completion. |
About
Origin story
Dr. Gitlin and colleagues recognized that a common challenge caregivers face when caring for a person living with dementia is the neuropsychiatric behaviors they display such as apathy, depressed affect, lability, agitation, and aggressiveness. Caring for a person living with dementia that experiences neuropsychiatric behaviors can contribute to caregi
...
Dr. Gitlin and colleagues recognized that a common challenge caregivers face when caring for a person living with dementia is the neuropsychiatric behaviors they display such as apathy, depressed affect, lability, agitation, and aggressiveness. Caring for a person living with dementia that experiences neuropsychiatric behaviors can contribute to caregiver distress, depression, increased care costs, and risk for long term care placement. As a response to the growing number of people living with dementia and the prioritization of developing and testing non-pharmacological approaches to managing behavioral symptoms, Dr. Gitlin’s team developed the Tailored Activity Program (TAP).
The Safer Aging Through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative's (QUERI) objective is to implement four evidence-based practices in VISN 4 that align with the 4 Ms of an Age-Friendly Health System to improve care for Veterans 65+ and help them age safely in place. TAP was chosen as the evidence-based practice to primarily address "Mentation".
Original team
Connor Warren, OTR/L
SAGE QUERI, TAP-VA Project Manager
Rebecca Brown, MD, MPH
SAGE QUERI, Principal Investigator and TAP-VA Lead
Robert Burke, MD, MS
SAGE QUERI, Principal Investigator
Comment
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