Close to 50 million families provide more than 85% of long-term care to older adults with complex chronic conditions. Family caregivers (CGs) typically assume care responsibilities without training or support and may in turn experience multiple health risks themselves including depression. Identifying innovative approaches for reaching this large population and providing evidence-based supportive programs to enhance their well-being is a public health imperative. One approach to reach CGs is to augment existing community-based services with an evidence-based program. Adult day service (ADS) is one such growing and critical community-based option that CGs of older adults with complex conditions rely on. ADS programs offer out-of-home, supervised activities but do not routinely provide evidence-based supportive CG programs. Also ADS use is not con- sistently associated with reductions in CG depressive symptoms, client behavioral symptoms and nursing home admissions. Thus, ADS is an ideal ?test bed? for translating a proven CG intervention to reach and support underserved CGs. We previously developed and evaluated in a small trial, ADS Plus, a program augmenting ADS with systematic support (e.g., education, skill building) to CGs. We showed that ADS Plus in comparison to usual ADS, reduced CG depression and nursing home placement. In response to NIA PA-14- 161 calling for translational research to integrate evidence-based models into existing services, we propose a practical trial design to assess the effectiveness and uptake of ADS Plus on a large scale. We will involve 30 ADS programs throughout the U.S. varying in geographic location and staffing levels and 300 CGs (150 in ADS Plus sites; 150 in ADS usual care sites). We will use cluster and re-randomization techniques, mixed methods, and cost analyses to rigorously evaluate program effectiveness and implementation processes. If effective, and with consultation from a Translation Advisory Board of key ADS leaders, ADS Plus will be disseminated widely. Primary study aims are to: 1) evaluate the effectiveness of ADS Plus to improve CG well-being and reduce depressive symptoms compared to routine ADS use at 6 months (Hypothesis 1: CGs in ADS Plus will report improved well-being and reductions in depressive symptoms compared to those in routine ADS only); and 2) evaluate long-term maintenance effects of ADS Plus at 12 months on CG well-being and depressive symptoms (Hypothesis 2: CGs using ADS Plus will maintain benefits from 6 to 12 months). Additional study aims will: 3) evaluate whether CGs using ADS Plus are more likely to maintain relatives in ADS and less likely to place them in residential settings compared to those in routine ADS over 12 months; 4) estimate ADS Plus costs and assess whether it results in net financial benefits when compared to usual ADS at 6 and 12 months; 5) evaluate the effects of ADS Plus on client behaviors and CG efficacy and upset managing symptoms; and 6) evaluate theoretically-derived (RE-AIM, Stress Process Model) mediational pathways of treatment change including CG acceptance and staff adoption of ADS Plus over 12 months.
We propose a translational research study to evaluate the effectiveness, cost benefit and implementation potential of a novel caregiver support program embedded in adult day services for older adults with complex conditions called ADS Plus. Using a practical trial design with cluster, re-randomization and mixed methodological techniques, we will involve 30 adult day services across the United States and 300 of their family caregivers and older adult clients, reflecting diversity in geographic location and background characteristics. Evaluating the effectiveness and implementation potential of caregiver support programs embedded in community-based long-term services reflects a national priority to increase the availability of financially feasible and effective services to chronically impaired older adults and their family caregivers.
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