ECHO-AGE: An Innovative Model of Geriatric Care for Long-Term Care Residents With Dementia and Behavioral Issues

doi:10.1016/j.jamda.2014.08.014

Journal of the American Medical Directors Association

Volume 15, Issue 12, December 2014, Pages 938-942

https://doi.org/10.1016/j.jamda.2014.08.014 Get rights and content

Abstract

Objectives

To design, implement, and assess the pilot phase of an innovative, remote case-based video-consultation program called ECHO-AGE that links experts in the management of behavior disorders in patients with dementia to nursing home care providers.

Design

Pilot study involving surveying of participating long-term care sites regarding utility of recommendations and resident outcomes.

Setting

Eleven long-term care sites in Massachusetts and Maine.

Participants

An interprofessional specialty team at a tertiary care center and staff from 11 long-term care sites.

Intervention

Long-term care sites presented challenging cases regarding residents with dementia and/or delirium related behavioral issues to specialists via video-conferencing.

Methods

Baseline resident characteristics and follow-up data regarding compliance with ECHO-AGE recommendations, resident improvement, hospitalization, and mortality were collected from the long-term care sites.

Results

Forty-seven residents, with a mean age of 82 years, were presented during the ECHO-AGE pilot period. Eighty-three percent of residents had a history of dementia and 44% were taking antipsychotic medications. The most common reasons for presentation were agitation, intrusiveness, and paranoia. Behavioral plans were recommended in 72.3% of patients. Suggestions for medication adjustments were also frequent. ECHO-AGE recommendations were completely or partially followed in 88.6% of residents. When recommendations were followed, sites were much more likely to report clinical improvement (74% vs 20%, P < .03). Hospitalization was also less common among residents for whom recommendations were followed.

Conclusions

The results suggest that a case-based video-consultation program can be successful in improving the care of elders with dementia and/or delirium related behavioral issues by linking specialists with long-term care providers.

Section snippets

Methods

The research protocol was approved by the Institutional Review Board at Beth Israel Deaconess Medical Center. A waiver of informed consent was obtained to review medical records and interview nursing home providers.

ECHO-AGE is based on the Extension for Community Healthcare Outcomes (Project ECHO) intervention developed by Dr Sanjeev Arora to similarly address shortages of knowledge and medical staff for the management of Hepatitis C in rural New Mexico.4, 5 After more than a decade of rigorous

Baseline Characteristics

Of the 47 participants presented in the first year pilot of ECHO-AGE, 12 were male and 35 were female. They ranged in age from 49 to 103 years with a mean age of 82 years (SD = 12.6 years). Participants resided at the long-term care facility for a median of 18 months. Medicare and Medicaid were the primary payers in 91% of cases. Eighty-three percent of participants had a reported history of dementia and 36.2% were noted to have suffered from delirium previously. They were taking an average of

Discussion

We conducted a pilot study to evaluate the experiences and outcomes of a video-consultation program, which sought to improve the care of elders with dementia and/or delirium related behavioral issues by linking specialists with long-term care providers. Prior studies have evaluated the utility of telemedicine in nursing home care and found improved patient outcomes, including decreased hospitalizations, when the service was used on a regular basis.⁷ In addition, literature suggests that

Conclusions

This pilot study evaluated the experiences and outcomes of a video-consultation program for long-term care providers focused on residents with dementia and/or delirium and behavioral issues. Overall, involved sites were highly committed to the program and often presented patients to the specialty team on multiple occasions. Among the patients in whom ECHO-AGE recommendations were followed, the long-term care sites reported clinical improvement, a trend toward decreased hospitalization, and

Acknowledgments

The authors acknowledge the contributions of Peter Macaulay, Daniel Press, MD, Jason Strauss, MD, and Jan Chiampa, LSW, and Marybeth Howard, MA to the ECHO-AGE project. They would also like to recognize the generous support of the Rx Foundation and The Patrick and Catherine Weldon Donaghue Medical Research Foundation. Dr Lipsitz holds the Irving and Edyth S. Usen and Family Chair in Geriatric Medicine at Hebrew SeniorLife, Boston, MA.

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Citation Excerpt :
We found that TM interventions in patients with BPSD were effective. VC modalities were useful in nursing homes where professional caregivers can support the patients.22,25,26 In one study that we did not include in the review due to the lack of diagnosed dementia, a computer-based care modality was shown to be more effective in reducing NPS in outpatients mildly cognitively impaired,45 relative to interventions focused on the caregivers27,28,30 or the dyad38 where the improvement in behavioral problems was modest.
The first-line management of behavioral and psychological symptoms of dementia (BPSD) is based on nonpharmacologic interventions such as the provision of guidance and medical support to caregivers. However, accessibility to specialized care and medical resources is often scarce. The ongoing COVID-19 pandemic has compromised the delivery of outpatient care (notably in order to minimize the risk of disease transmission), thus making it essential to provide other means of accessing care for these patient populations. The use of telemedicine (TM) may be a means of increasing access to specialist care for patients with disabilities and poor access to health services, such as those with BPSD. The aim of this study is to provide a review of the literature on the use of TM for treatment and follow-up of patients with BPSD and their caregivers.
We searched the PUBMED, EMBASE and CINAHL for articles published between January 1st, 2000, and December 31st, 2020, on the applicability of TM support for people with BPSD and their caregivers. We included open-label studies, qualitative studies, and randomized controlled trials . We did not include studies on the use of TM during the COVID-19 pandemic.
A total of 22 publications were included and reviewed. TM was found to 1) be acceptable and feasible for both patients and caregivers, 2) decrease the frequency and intensity of BPSD, and 3) improve the caregiver's perceived wellbeing and mental health. Videoconferencing was effective for patient-centered interventions in nursing homes. Telephone-based interventions were more relevant when they were targeted at caregivers.
The published studies are lacking in scope and high-quality studies are now needed to confirm these findings and assess TM's cost-effectiveness and ability to improve the management of patients with BPSD. In view of the ongoing COVID-19 pandemic, remote solutions for assessing and monitoring individuals with BPSD are urgently needed - particularly those living in rural areas and so-called “medical deserts.”
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: The authors declare no conflicts of interest.

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Clinical ExperienceECHO-AGE: An Innovative Model of Geriatric Care for Long-Term Care Residents With Dementia and Behavioral Issues

Abstract

Objectives

Design

Setting

Participants

Intervention

Methods

Results

Conclusions

Section snippets

Methods

Baseline Characteristics

Discussion

Conclusions

Acknowledgments

Arch Intern Med

Int J Med Inform

Antipsychotic medication use in nursing homes: A proposed measure of quality

Int J Geriatr Psychiatry

CMS seeks to reduce antipsychotic use in nursing home residents with dementia

JAMA

Clinical Experience
ECHO-AGE: An Innovative Model of Geriatric Care for Long-Term Care Residents With Dementia and Behavioral Issues