Provider-Caregiver Interactions: Evaluation and Use of the Therapeutic Relationship Index for Caregiver Interventions Yeon Kyung Chee, Marie P. Dennis, Laura N. Gitlin Community and Homecare Research Division Thomas Jefferson University, Philadelphia Paper Presented at the Annual Meeting of the Gerontological Society of America, November 23, 2003 Funded by NIA R01 AG10947 and NIA/NINR U01 AG13265

Objectives Examine psychometric properties of the Therapeutic Relationship Index (TRI) Examine utilities of the TRI for in-home caregiver behavioral interventions

Effective Caregiver Interventions: In-home Interventions vs Traditional Medical Settings Personal relationship with caregiver Individualized approach/Customization Sense of empowerment Shared responsibility Mittelman et al, 1996; Pusey & Richard 2001; Schulz et al, 2002; Clark et al, 1995; Gitlin & Gwyther, 2003; Toth-Cohen et al, 2001

Collaborative Treatment Approach Patient-Centered Care (Institute of Medicine, 2001) Responsive to patient values, preferences Making health care decisions jointly with patients Positive association with compliance: Improved health status/role performance Reduced health services utilization Satisfaction with medical care Holman & Lorig, 2000; Stewart, 2001; Von Korff et al, 1997; Greenfeld et al, 1985; Lorig et al, 2001; Roter 2000; Stewart 2001

Specific Aims Evaluate psychometric properties of the Therapeutic Relationship Index Examine changes over time and differences in TRI scores between intervention completers vs dropouts Examine the relationship TRI scores and caregiver characteristics

Study Participants: Inclusion Criteria Drawn from randomized clinical trials: Recruited from Philadelphia Corporation on Aging, memory clinics, social services, media announcements 21 years of age or older Primary caregiver of persons with a diagnosis of ADRD or MMSE <24 Living with care recipient Deficiencies in 1+ ADLs Deficiencies in 2+ IADLs

Study Participants Sample 1: Dementia Management Study Sample 2: REACH I (Resources for Enhancing Alzheimer’s Caregiver Health) at the Philadelphia site Environmental Skill-building Program (ESP) Gitlin et al, 2001; Gitlin et al, 2003; Wisniewski et al, 2003

Study Participants Sample 1: 99 of 100 intervention group 8 did not receive ESP 27 dropouts (< 5 visits) Refusal, Bereavement, Placement No statistical or large differences between dropouts (n=27) vs completers (n=91)

Study Protocol Sample 1: Sample 2: Five 90-min visits over 3 months Active: Five 90-min visits, one phone contact over 6 months Maintenance: One 90-visit, three phone contacts over 6 months

Interventions Communication Setting up home environment Managing difficult behaviors Alleviating stress Treatment documentation completed by interventionists within 48 hours following each visit

Therapeutic Relationship Index (TRI) 14 item, 5-point scale Provider perceptions Patient-centered care, dementia caregiving, ethical considerations in caregiving Focus group discussions with occupational therapists Higher scores = More collaborative

Measures of Construct Validity Caregiver readiness (Prochaska & Velicer, 1997) 1 precontemplation 2 contemplation 3 preparation 4 action/maintenance Caregiver anxiety (STAI) Care recipient behavioral problems (RMBPC) Care recipient cognitive impairment (MMSE) Care recipient functional dependence (ADL)

Scale Structure Sample 2 Principal Components Model: Factor loadings ranged from .50 to .84 (all 14 items) Openness Connectedness Information-Seeking

Reliability Internally consistent: α = .78 (Sample 2) Openness: α = .77 Connectedness: α = .66 Information-Seeking: α = .72 Six-month test-retest: Five visits (Sample 2) Ranged .78 to .84 Intraclass correlations: Five visits (Sample 2) α = .90

Construction Validity Sample 2 Total index and subscales Openness Connectedness Information-Seeking Caregiving-related measures

Changes in TRI scores over time: Completers vs Dropouts Sample 2 Repeated measures analysis with the Huyne-Feld solution Significant interaction (F (1.95, 202.57) = 9.89, p < .001) Completers showed improvements (M = 42.02) Dropouts showed a drop (M = 38.72)

Association of TRI scores to Caregiver Characteristics Sample 2 Caregiver age, gender, race, income, education, length of caregiving, relationship to care recipient Caregiver characteristics were not associated with TRI scores (R2 = .090, F (7, 110) = 1.546, p = .159)

Conclusions and Implications Lack of an adequate measure to evaluate therapeutic relationships for home-based interventions 14-item TRI is valid and internally consistent Openness Connectedness Information-Seeking TRI is associated with readiness, anxiety, behavioral problems not with functional status Use of entire scale vs subscales: Therapeutic Relationships are complex and nuanced

Conclusions and Implications Factors other than demographic profile influence the collaborative treatment process TRI is sensitive to detect improvement or decline in therapeutic relationships with caregivers among completers and dropouts For development of strategies to enhance compliance and customize intervention to match caregiver needs Determine factors that contribute to poor collaboration and premature dropout from intervention Examine relationships between TRI scores and treatment outcomes