veterans’ (and their families’) satisfaction with health care.
METHODS
Dementia evaluations were conducted
by a geriatric nurse practitioner and
psychology technician teamlet at the
CBOCs. In addition to neuropsycho-logical testing, medical records were
reviewed, caregivers were interviewed,
and the patients were examined. The
data were then brought back to the
full BVAMC Geriatrics/Dementia Clinic multidisciplinary team
for discussion. The team reached a
consensus diagnosis and then made
a comprehensive plan for the further evaluation and management of
these complex patients. The plan
was entered into the Computerized
Patient Record System and communicated to the patient and caregiver
during a follow-up CBOC visit.
The teamlet frequently provided
informal education during CBOC
visits in addition to formal lectures
given by experts from the BVAMC
and the University of Maryland. The
DEMO program was introduced to
providers at the CBOCs by e-mail
with follow-up information sessions
provided on site.
Rather than having patients simply
return to their CBOC primary care
providers (PCPs) and exposing patients to the risks of poor communica-tion/coordination of care, services were
expanded to include regular phone
follow-up calls with case management
services that augmented those of their
PCPs. The goal was to improve outcomes for these patients and provide
alternatives to institutionalization.
Standardized instruments were
used to gauge patient and caregiver
satisfaction, obtain cost data from the
VA and the Centers for Medicare &
Medicaid Services, and medication
data from the Pharmacy Benefits files.
The institutional review board
provided approval to collect data on
participants to assess the program’s
clinical and economic impacts.
Since all patients were suspected
to have dementia, the informed
consent procedures included ad-
ditional protections. The patient’s
understanding of the pertinent in-
formation related to participation in
the study was assessed to help en-
sure that participants with demen-
tia truly understood the conditions
to which they were consenting. If
the potential participant could not
provide informed consent, it was
obtained from a surrogate with du-
rable power of attorney (the person
recognized by Maryland law as the
substitute decision maker or the vet-
eran’s legal guardian). Consent was
assessed on an ongoing basis re-
gardless of the patient’s capacity to
give informed consent, and those
willing to have their data collected
were enrolled in a “research” arm.
These participants were compared
with veterans in the dementia clinic
during the enrollment period but
who did not consent to participate
in the research arm, controlling for
Gender 97% male
Race 64% white, 36% black
MMSE 22. 2 ± 5.0 2-30
GDS 7. 8 ± 5. 6 0-26
Tinetti Gait & Balance 21. 7 ± 7.0 1-30
ADL 9. 9 ± 5.0 6-28
IADL 15. 5 ± 10. 6 0-30
Dementia Diagnosis Type
None 9.2%
Cognitive disorder NOS 10.7%
MCI 13.0%
Dementia NOS or mixed dementia 46.6%
Vascular dementia 19.1%
Senile dementia of the Alzheimer type 1.5%
Abbreviations: ADL, activities of daily living; GDS, Geriatric Depression Scale; IADL, instrumental
activities of daily living; MCI, mild cognitive impairment; MMSE, Mini-Mental State Examination;
NOS, not otherwise specified; SEM, standard error of the mean.
