Care managers with special training play a particularly important role. They visit patients at their homes to compile a detailed profile of their care situation. For this, comprehensive interviews are conducted with the assistance of tablet-PCs. Based on the collected information a computer program generates specific recommendations for the treating general practitioner (GP). The new procedure is part of a comprehensive concept the DZNE is currently testing in cooperation with the University Medicine Greifswald with the aim of improving home care services for dementia patients.
Dementia is a complex condition that involves not only physical, but also psychological, social and legal aspects. “We need all-encompassing care solutions that are individually tailored to the needs of patients and their care providing family members,” says Professor Wolfgang Hoffmann, Speaker of the DZNE-Site Rostock/Greifswald, and Managing Director of the Institute for Community Medicine at the University Medicine Greifswald. The complexity of this task prompted the researchers to develop a computerized Intervention-Management-System (IMS). “The software matches individual patient characteristics with a knowledge base that describes the conditions for optimum care for dementia patients,” explains Dr. Tilly Eichler, a scientist at the DZNE in Greifswald. Testing of the system has been underway in the Federal State of Mecklenburg-Vorpommern since January 2013 and first results are now available. The analysis is part of “DelpHi-MV,” an interventional study conducted by the DZNE to evaluate new approaches for home care for dementia patients.
Care managers are testing the new system under practical conditions
The study participants – dementia patients age 70 and older – are supported by specially trained care professionals. These “dementia care managers” (DCM) visit patients at their homes. Their responsibilities include comprehensive interviews. Among other matters, a DCM records health problems, medications, the frequency of doctors’ appointments, and also if patients have authorized someone to make medical decisions on their behalf. In this way, the DCM systematically assess the individual needs of patients covering medical, nursing care, pharmaceutical, psychological, social as well as legal aspects. For data collection, tablet-PCs that run the IMS are used. The computer program subsequently recommends specific actions for the patient’s GP.
The objective: the provision of care tailored to the patient’s needs
The IMS proposes up to 28 different measures for the provision of care and treatment – so-called interventions. For instance, if the interview points to a depression, a referral to a psychiatrist will be recommended to clarify the patient’s actual condition. If patients have difficulty handling everyday tasks such as getting dressed or brushing their teeth, the IMS will suggest ergo-therapy. DCMs do have the option to revise these recommendations if they deem it necessary. All changes are documented. “Ultimately, this results in a GP-information letter, which contains decision-making aids for a tailored care and treatment plan,” Eichler explains. “The GP decides, which actions are in fact initiated and implemented in cooperation with the dementia care manager.”
A DCM will accompany the implementation of the intervention plan for at least half a year, thereby providing patients and their relatives customized support in handling the disease. This assistance which is provided in the context of regular visits to the patient’s home aims to pave the way for good and sustainable care. “We want to integrate dementia patients and their families into the regionally available healthcare system as early as possible. Our goal is that they take the best benefit from these resources”, Eichler comments.
Software uncovers unmet needs
An initial analysis has shown that the new computer program does provide effective support to the DCM when it comes to the identification of unmet needs. This conclusion comes from comparing two patient groups: for one group, the search for unmet needs was based on a manual questionnaire. For the second group, the questionnaire was computerized. The result: the IMS identified needs that had not been discovered by the manual analysis.
“The number of interventions recommended to the general practitioner increased by 85 percent as a result of using the IMS,” Professor Hoffmann says. “Consequently, our dementia care managers were able to provide more effective support to dementia patients and their care giving relatives.”
“The IMS does provide the general practitioner with more concise insights into the patient’s status along with specific recommendations for actions to be taken,” Hoffmann adds. “We will now study, which interventions are actually being implemented and what their effects are. Ultimately, our aim is to improve the patients’ quality of life and to relieve their families.“
In the context of “DelpHi-MV”, a scientific study initiated in January 2012, the DZNE is investigating the impact and practicability of various actions for providing home care to dementia patients. Interventions conducted by dementia care managers are central to the study. Family members also receive consulting services or are offered special training. This aims to facilitate the provision of home care to dementia patients and to relieve care giving relatives.
To date, more than 125 general practitioners and more than 480 patients are participating in the study in the Federal State of Mecklenburg-Vorpommern. Additional study participants are expected to join in the course of this year. The initial results on the effectiveness of dementia care management are anticipated by early 2016. The DZNE aims to integrate this concept of outpatient services into routine care.
“The benefits of implementing a computerized Intervention-Management-System (IMS) on delivering integrated dementia care in the primary care setting”, Tilly Eichler, Jochen René Thyrian, Daniel Fredrich, Leonore Köhler, Diana Wucherer, Bernhard Michalowsky, Adina Dreier, Wolfgang Hoffmann, International Psychogeriatrics, 2014,