Feasibility of a Systems Approach for Alzheimer's Services Among Latinos Attending Primary Care Practices

Phase 1

Completed

Conditions: Dementia

Interventions: Combination Product: Alianza Latina

Registration Number: NCT04418232

Lead Sponsor: University of Kansas Medical Center

Brief Summary: The research team will train primary care practitioners from Kansas City clinics to enhance skills in cultural competence, dementia detection, treatment and referral to a Health Navigator among Latinos 65 and older with dementia. The Health Navigator will provide patient/caregiver dyads referred by Alianza Latina providers with care management, psychosocial support and links to relevant community resources. Outcomes include feasibility and acceptability of 1) PCP training and 2) patient and caregiver dementia care.

Detailed Description: Alzheimer's disease and related dementias (ADRD) are a major cause of mortality and disability in later life and cost the US healthcare system more than cancer or heart disease. The National Alzheimer's Plan Act and the National Institutes of Health have identified ADRD disparities among ethnic minorities as a public health priority. Latinos with ADRD experience substantial disparities with reduced rates of early diagnosis and lower quality care compared to their non-Latino white peers, which put them at an increased risk for steeper cognitive decline, morbidity, mortality and higher caregiver burden. A number of barriers conspire to create these disparities including a lack of an evidence-based strategy to address ADRD in clinics, patient and primary care provider (PCP) reduced ADRD knowledge, negative attitudes regarding ADRD, PCP's lack of time, cultural and language barriers and health insurance status. To improve healthcare delivery to Latinos with ADRD, researchers need to redesign current ADRD detection and care systems to follow evidence-based recommendations for early detection and culturally appropriate chronic care.

The overall aim of this proposal is to enhance the delivery of ADRD services to Latinos in primary care through a scalable systems approach that includes evidence-based recommendations. Primary care clinics are the ideal setting to provide ADRD services, as 93% of older Latinos have a usual source of healthcare. The novel systems approach (Alianza Latina/Latino Alliance) will enhance timely ADRD diagnosis and optimal care to minimize behavioral symptoms and cognitive decline among Latinos in a linguistically and culturally-appropriate way. Alianza Latina will use the Collaborative Care Framework that capitalizes on PCPs and Health Navigators. 1) PCPs will undergo evidence-based training to enhance timely and culturally appropriate diagnosis and implement it in their work routine. 2) PCPs will detect, treat and refer Latino ADRD patients to a bilingual Health Navigator to provide chronic care management, which will reduce PCP time burden.

Aim 2: Test the feasibility and acceptability of Alianza Latina. Aim 2.a: The research team will train PCPs from Kansas City clinics to enhance skills in cultural competence, ADRD detection, treatment and referral to a Health Navigator among Latinos 65 and older with ADRD. Aim 2.b. The Health Navigator will provide patients/caregiver dyads referred by Alianza Latina PCPs with care management, psychosocial support and links to relevant community resources. The research team will assess the feasibility and acceptability of 1) PCP training and 2) patient and caregiver ADRD care. Caregivers will be enrolled in a text messaging program, called CuidaTEXT, that will educate about memory and thinking problems, solve problems that are common among families with memory and thinking problems, send reminders for appointments and medications, and improve communication with the PCP, family, friends, and other resources.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 243

Inclusion Criteria

Not provided

Exclusion Criteria

Not provided

Study & Design

Study Type: INTERVENTIONAL

Study Design: SINGLE_GROUP

Arm && Interventions

Group	Intervention	Description
Alianza Latina	Alianza Latina	The main components of Alianza Latina are 1) providing primary care providers with education, training and tools for timely dementia diagnosis and optimal treatment and 2) providing Latino dementia patients with enhanced chronic care through bilingual Health Navigators.

Primary Outcome Measures

Name	Time	Method
Provider Recruitment Feasibility	During the 9 months of the provider intervention period	Metrics of the number of providers who agree to be trained per month
Provider Retention Feasibility	During the 9 months of the provider intervention period	Metrics of the percentage of providers who continue to partner with the study team by the end of the provider intervention period
Provider Fidelity Feasibility 1	9 months (end of the provider intervention period)	Percentage of providers able to implement screenings in regular workflow, measured via survey with the question "To what extent were you able to implement screenings in regular workflow" with three response options: "not at all", "to some degree", "usually", "almost always" and "always"
Provider Assessment Feasibility 1	During the 9 months of the provider intervention period	Metrics of the percentage of providers who complete baseline and follow-up surveys about dementia knowledge, attitudes and skills
Provider Fidelity Feasibility 2	During the 9 months of the provider intervention period	Metrics of the Number of referrals to Health Navigator per month
Overall Provider Satisfaction With Training	9 months (end of the provider intervention period)	Survey question including a 5-item Likert scale on satisfaction with training (not at all to very much)
Importance of Navigators to Providers	9 months (end of the provider intervention period)	Survey question including a 5-item Likert scale on the perceived importance of Navigators to providers (not at all to very much)
Participant Recruitment Fidelity	During the 15 months of the whole intervention period	Metrics of percentage of referred Latino dementia dyads who enroll in Health Navigator services
Participant Retention Fidelity	During the 6 months of the Navigator intervention period	Metrics of percentage of referred Latino dementia dyads followed up at six months
Participant Assessment Fidelity	During the 6 months of the Navigator intervention period	Metrics of the percentage of planned baseline and follow-up survey ratings completed
Participant Treatment Adherence	During the 6 months of the Navigator intervention period	Metrics of the percentage of referred Latino dementia dyads who attend at least 50% of Health Navigator visits
Overall Participant Satisfaction With the Clinic Side of the Intervention	6 months after baseline	Survey question including a 5-item Likert scale on caregivers' satisfaction with clinic services (not at all to very much)
Overall Participant Satisfaction With the Navigator Side of the Intervention	6 months after baseline	Survey question to the caregiver including a 5-item Likert scale on satisfaction with Navigator services (not at all to very much)
Participant Suggestions of Improvement	6 months after baseline	Survey question to the caregiver including an open-ended question about which aspects of the intervention they would change
Practitioner Adherence to Guideline Recommendations	6 months after baseline	10-item checklist administered to the dyads asking about the implementations of different aspects of dementia service guidelines

Secondary Outcome Measures

Name	Time	Method
Patients' Behavioral Symptoms	Baseline and 6 months from baseline	Brief version of the Neuropsychiatry Inventory Questionnaire: This is a validated clinical instrument for evaluating psychopathology in dementia. If any of the 12 neuropsychiatric symptoms is present, caregivers rate their loved one's severity on a three-point scale (mild-severe). For example, if the caregiver responds yes to "is the patient resistive to help from others at times, or hard to handle?", the following question would follow: "rate the severity of the symptom". An overall severity summary score is calculated by adding the severity scores of all items, ranging from 0 to 36, and higher scores mean higher severity.
Patients' Depression	Baseline and 6 months from baseline	Short Geriatric Depression Scale: This scale measures depressive symptomatology, and consists of 15 yes vs no questions. Of the 15 items, 10 indicate the presence of depression when answered positively, while the rest (question numbers 1, 5, 7, 11, 13) indicate depression when answered negatively. A summary score is obtained ranging from 0 to 15, with higher scores meaning more severe depressive symptomatology.
Patients' Quality of Life	Baseline and 6 months from baseline	Quality of Life in Alzheimer's Disease: The Quality of Life in Alzheimer's Disease is comprised of 13 items (physical health, energy, mood, living situation, memory, family, marriage, friends, self as a whole, ability to do chores, ability to do things for fun, money and life as a whole). Response options include 1(poor), 2(fair), 3(good) and 4 (excellent), for a total score of 13-52, with higher scores indicating better quality of life.
Caregivers' Quality of Life	Baseline and 6 months from baseline	In general, how satisfied are you with your life?" with a 4-point scale from 1 (Very Satisfied) to 4 (Very Dissatisfied)
Caregivers' Depression	Baseline and 6 months from baseline	10-item Center for Epidemiologic Studies-Depression scale (CES-D-10): This is a 10-item, self-report rating scale that measures characteristic symptoms of depression in the past week (e.g. depression, loneliness, restless sleep). Each item is rated on a 4-point scale, from 0 (rarely or none of the time) to 3 (most or all of the time) with positively worded items (items 5 and 8) reverse scored. Items yield summary scores that range from 0 to 30, with higher scores indicating higher severity. An example of an item is: "I was bothered by things that usually don't bother me"
Caregivers' Burden	Baseline and 6 months from baseline	Short Zarit Burden Interview: This caregiver burden scale has 6 items that address the perceived impact of the act of providing care on the physical health, emotional health, social activities and financial situation of the caregiver. Each item has five response options ranging from "never" to "nearly always". A total score is obtained by adding scores in all items, with a range from 0 to 24. Higher scores mean higher burden.