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Home and community-based services (HCBSs) such as home care and adult day centers are vital to supporting adults with dementia in community settings. We investigated whether HCBS use (use of both home care and adult day, use of one service, and use of neither service) varied between adults receiving care from three types of health-care teams with case management from social workers and nurses, and by comorbidity level, using 2019 data of 143,281 patients with dementia in the Veterans Health Administration. We compared HCBS use by patients' type of case-managed team (Home-Based Primary Care, geriatrics-based primary care, and dementia-focused specialty care) to patients in none of these teams, stratified by patients' non-dementia comorbidities (<4 or ≥4). Each type of health-care team was associated with both home care and adult day services, at each level of comorbidity. Home-Based Primary Care was most consistently associated with other forms of HCBS use, followed by Dementia Clinics and geriatrics-based primary care, for patients with ≥4 non-dementia comorbidities. Our findings suggest that case management in primary and specialty care settings is a contributor to the use of critical community supports by patients with the most complex needs.

Background: Half of the 4.7 M veterans who reside in rural communities and rely on U.S. Department of Veterans Affairs (VA) health care are older (≥65). Their rurality presents unique challenges, including a shortage of clinicians skilled in geriatric medicine. Community-based outpatient clinics (CBOCs) help extend VA's geographic reach but are typically located in under-resourced settings. Telemedicine may increase access to care, but little is known about CBOCs' capacity to leverage telemedicine to meet older patients' needs. We identified organizational barriers and facilitators to the use of geriatric telemedicine specialty care from the perspective of rural clinicians and staff., Methods: From February-April 2020, we interviewed CBOC clinicians and staff (N = 50) from 13 rural CBOCs affiliated with four VA Geriatric Research Education and Clinical Centers. Semi-structured interviews addressed patient population characteristics; CBOC location, staffing, and in-house resources; use of VA specialty care services; and telemedicine use. We developed a codebook using an iterative process and Gale's Framework Method thematically organize and analyze data., Results: Respondents perceived that their CBOCs serve a predominantly older patient population. Four characteristics enabled CBOCs to offer geriatric telemedicine specialty care: partnerships with larger VA Medical Center teams; social worker/telehealth clinical technician knowledge of geriatrics and telehealth resources; periodic outreach/education from geriatric specialists; and routine use of other telehealth services. Barriers included: constraints on clinic space and unstable internet for telemedicine visits; staffing challenges leading to limited familiarity with telemedicine resources; and clinician and staff perceptions of older veterans' preference for in-person visits., Conclusions: Telemedicine is an important modality to enhance access to care for an increasingly older and medically complex patient population. Although rural CBOCs provide a large portion of care to VA's growing geriatric population, staff are insufficiently trained in geriatrics, work in resource-poor settings, and are largely unaware of VA telemedicine programs designed to support them., (© 2023 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Introduction: US veterans have a unique dementia risk profile that may be evolving over time., Methods: Age-standardized incidence and prevalence of Alzheimer's disease (AD), AD and related dementias (ADRD), and mild cognitive impairment (MCI) was estimated from electronic health records (EHR) data for all veterans aged 50 years and older receiving Veterans Health Administration (VHA) care from 2000 to 2019., Results: The annual prevalence and incidence of AD declined, as did ADRD incidence. ADRD prevalence increased from 1.07% in 2000 to 1.50% in 2019, primarily due to an increase in the prevalence of dementia not otherwise specified. The prevalence and incidence of MCI increased sharply, especially after 2010. The prevalence and incidence of AD, ADRD, and MCI were highest in the oldest veterans, in female veterans, and in African American and Hispanic veterans., Discussion: We observed 20-year trends of declining prevalence and incidence of AD, increasing prevalence of ADRD, and sharply increasing prevalence and incidence of MCI., (© 2023 the Alzheimer's Association.)

Objectives: Quality dementia care, which recognizes caregivers as vital care partners, is a scarce resource. Innovative solutions like video telehealth may increase the reach of extant clinicians; however, little is known about perceived barriers and facilitators to in-home video telehealth for dementia management from the perspectives of caregivers., Methods: Twenty-four caregivers of community-dwelling Veterans with dementia participated in semi-structured interviews. Questions gathered perceived facilitators and barriers to in-home video telehealth for dementia management through experience with related technology. Transcripts were analyzed using directed content analysis which was guided by factors previously identified as influencing older adults' adoption of technology., Results: Caregiver experience with related technology was mostly facilitative to video telehealth, which was thought best suited for follow-up care. Increased access and decreased patient-caregiver stress were potential benefits. Barriers included perceived limitations of video and the belief that persons with dementia would have limited ability to manage technological aspects and to engage in video telehealth on their own., Conclusions: This study improves our understanding of the factors that caregivers perceive as barriers and facilitators to in-home video telehealth for dementia management., Clinical Implications: Strategies to optimize video telehealth include capitalizing on caregivers' social network and providing targeted training.

Objectives : This pilot project aimed to explore a new model of healthcare delivery to older adult medically complex Veterans by combining telehealth technology with an interdisciplinary medical team operating in real time. Methods : The Geriatric-Interdisciplinary Mobile Patient Access Team (G-IMPACT) was comprised of a field team including a nurse practitioner and technology assistant who visited enrolled patients in their homes using synchronous video to link to a suite of geriatric specialists in a video-enabled room at a Veterans Affairs hospital. Clinicians interacted with patients, caregivers, and each other to develop mutually agreed upon treatment plans that were then immediately implemented in the field. Results : 11 total visits were conducted with 9 Veteran patients aged 55-91 (mean = 75.3 years). Both patients and clinicians reported a high level of satisfaction across multiple metrics, including visit quality, and positive indirect indicators of effectiveness were apparent from qualitative data. Conclusions : Nurse practitioner facilitated video visits allowed geriatric patients to meet with multiple specialists simultaneously with both high patient satisfaction and increased real-time care coordination. Clinical Implications : This project identified challenges and opportunities afforded by this type of real-time telehealth care delivery and can inform the development of future interdisciplinary mobile medical teams.

Introduction: US veterans have a unique dementia risk profile that may be evolving over time. Methods: Age‐standardized incidence and prevalence of Alzheimer's disease (AD), AD and related dementias (ADRD), and mild cognitive impairment (MCI) was estimated from electronic health records (EHR) data for all veterans aged 50 years and older receiving Veterans Health Administration (VHA) care from 2000 to 2019. Results: The annual prevalence and incidence of AD declined, as did ADRD incidence. ADRD prevalence increased from 1.07% in 2000 to 1.50% in 2019, primarily due to an increase in the prevalence of dementia not otherwise specified. The prevalence and incidence of MCI increased sharply, especially after 2010. The prevalence and incidence of AD, ADRD, and MCI were highest in the oldest veterans, in female veterans, and in African American and Hispanic veterans. Discussion: We observed 20‐year trends of declining prevalence and incidence of AD, increasing prevalence of ADRD, and sharply increasing prevalence and incidence of MCI. [ABSTRACT FROM AUTHOR]

Video telehealth can increase access to home-based care, thus allowing older adults to maintain functional independence and age-in-place. This is particularly salient for persons with dementia whose cognitive changes increase home safety risk. Little is known about the technological and safety challenges of in-home assessment via video. This feasibility study explored the process and resource requirements of a remotely delivered telehealth occupational therapy home safety evaluation from a Veterans Health Administration (VHA) site. A total of 10 caregivers of veterans with dementia received home safety evaluations using videoconferencing technology using a variety of portable computing devices. Most telehealth evaluations experienced technological difficulties, but formal technical support was only required twice. Videoconferencing is a feasible service delivery option for home safety evaluations; however, infrastructure must support technological needs and client or provider gaps in knowledge. Implications for non-VHA settings and other interventions using videoconferencing are discussed. [ABSTRACT FROM AUTHOR]

Older adults' preference to age in place, coupled with an increasing prevalence of dementia, creates an imperative to address home safety risks that occur due to cognitive impairment. Providing caregivers with home safety items and education can facilitate ageing in place for older adults living with dementia. In 2015–2017, we examined barriers and facilitators within 17 policy documents and dementia guidelines of the United States (US) Veterans Health Administration pertinent to implementation of a home safety toolkit (HST) for Veterans living with dementia. The documents were issued from 2000 to 2015. Directed qualitative content analysis of these documents guided by themes from stakeholder interviews revealed two key implementation barriers: a focus on physical rather than cognitive risks when determining medical necessity for home equipment, and a focus on rehabilitation and treatment rather than prevention. Mandates for person‐centred care planning, including comprehensive assessment, interdisciplinary collaboration, staff education and a focus on population health in primary care facilitate HST implementation. Content analysis can identify policy‐level barriers that slow innovation and facilitators that can increase access to care that support ageing in place. [ABSTRACT FROM AUTHOR]