1. Clinical Research in Practice: Translation of Evidence-Based Dementia Caregiving Interventions in the VA Telephone Assisted Dementia Outreach Program Michelle M. Hilgeman, PhD Research Clinical Psychologist Research & Development Service Tuscaloosa VA Medical Center

2. 2 Overview Background: Veterans, Dementia, Dementia Caregiving, and the Problem of Translation Weaving together Research & Practice (as an early career VA researcher) – The Research Grant: Optimizing Dementia Outcomes in the Community (VA CDA1) Mixed Methods Interviews – The Clinical Grant: The Telephone Assisted Dementia Outreach (TADO) Program Translating Evidence-Based Interventions for Remote Delivery The BRI Care Consultation Model Computerized delivery system – The Next Research Grant (CDA2) Intervention development / translation – Sustaining the Clinical Infrastructure (Transitioning TADO into an interdisciplinary Memory and Aging Care Clinic) Questions/Discussion

3. 3 Background: Veterans Enrolled in the Veterans Health Administration (VHA) OEF = Operation Enduring Freedom (Afghanistan, 2001-present); OIF = Operation Iraqi Freedom (Iraq 2003-2010); OND = Operation New Dawn (Iraq post 2010) Almost half of Veterans in the VHA are over the age of 65, and over 7% of these individuals have dementia. Krishnan et al., 2005

4. 4 Background: Dementia in the VA Southeast region of the US has the highest rates of dementia in the country – Dementia occurs in 1 out of every 11 Veterans in VISN 7 (Alabama, Georgia, & S. Carolina) – “Stroke belt” – disparities in educational achievement, rurality, cardiovascular morbidities, and racial differences – Black / African American individuals are at increased risk of developing dementia Veterans seeking care for dementia at the VA will peak in 2017 Cost of care for individuals with dementia = 3 tx that of peers without a diagnosis Community and VA care settings are poor at early identification & treatment – Miss cost-saving crisis prevention; delay treatment & planning until crises occur (e.g., hospitalization, undesired institutionalization) Krishnan et al., 2005; Institute of Medicine, 2008; Yaffe et al. 2010:

5. 5 Conditions common in Veterans increase risk for developing dementia: – Post-Traumatic Stress Disorder (PTSD) – Traumatic Brain Injury (TBI) Yaffe et al. 2010: – Followed 181,093 veterans 55 yrs + without dementia from 1997 through 2007 – Veterans with PTSD were almost twice as likely to be diagnosed with dementia (10.6% compared to 6.6%) Background: Veterans at Increased Risk for Dementia

6. 6 Background: Caregivers and Veterans Omnibus Health Services Act of 2010 “We at VA are committed to providing the Family Caregivers who share our sacred duty to care for those ‘who have borne the battle’ with the best services available.” Former Secretary of Veterans Affairs Erik K. Shineski

7. 7 Background: Supporting the Caregiver & A Significant Translation Problem OA’s with Alzheimer’s disease – live on avg. 4-8 yrs after the diagnosis; though some survive as long as 20 yrs Sustained support of the caregiver is critical in order to impact rates of institutionalization which approach 50% by 5 years after diagnosis (Luppa et al., 2010) Numerous evidence-based treatments have been established for family caregivers and distressed individuals with dementia – Availability/access is severely limited (particularly in rural areas). – Many “remain on the shelf” after research trials A recent synthesis of data on translation/implementation from multiple healthcare settings (VA, IOM, Administration on Aging, Metlife Foundation, etc.) suggested that only 0.00025% of caregivers of individuals with dementia (or N = 37,783 / 15 million) have access to an evidence-based treatment program. (Gitlin, 2013)

8. INTEGRATING RESEARCH & CLINICAL PRACTICE +

9. 9 VA Career Development Award – Level I (CDA-1) 2 Year Mentored Award - Research Study, Career/Training Plan, Mentor Plan Eligibility = no research postdoc or significant grant as PI 100% Salary Support for PI / Awardee $0 to conduct the study (must piggyback on mentors work and/or get creative) Office of Rural Health Clinical Demonstration Grant (Clinical Pilot) Goal = increase access to evidence- based care, specialty care, etc. ORH Annual Budget: $250,000,000 (FY2009-FY2014) 1 year grants with opportunity to apply for sustainment (up to 3 years) Complementary Funding Opportunities Clinical ORH Funding (2012-2015) Research: CDA1 Funded (2013-2015) Research: CDA2 Funding (Hopefully - 2015- 2020) Clinical Transition TADO to Permanent Clinic (Hopefully TVAMC Funded) Future Research Grants

10. 10 VA Career Development Award – Level I (CDA-1) 2 Year Mentored Award - Research Study, Career/Training Plan, Mentor Plan Eligibility = no research postdoc or significant grant as PI 100% Salary Support for PI / Awardee $0 to conduct the study (must piggyback on mentors work and/or get creative) Office of Rural Health Clinical Demonstration Grant (Clinical Pilot) Goal = increase access to evidence- based care, specialty care, etc. ORH Annual Budget: $250,000,000 (FY2009-FY2014) 1 year grants with opportunity to apply for sustainment (up to 3 years) Complementary Funding Opportunities Clinical ORH Funding (2012-2015) Research: CDA1 Funded (2013-2015) Research: CDA2 Funding (Hopefully - 2015- 2020) Clinical Transition TADO to Permanent Clinic (Hopefully TVAMC Funded) Future Research Grants

11. OPTIMIZING DEMENTIA OUTCOMES IN THE COMMUNITY The RESEARCH GRANT: Career Development Award - Level I, 1IK1RX000791-01A1, Hilgeman PI. Funded by the VA Rehabilitation Research & Development (2013-2015). Lori Davis, M.D., Primary Mentor; Mentoring Team: Snow, Allen, & Kunik

12. 12 CDA-1: Outpatient Needs Assessment (ONA) Qualitative Interviews with Veterans with Dementia and their Caregivers GOAL: To identify perceived needs and gaps in VA rehabilitation and health care support for Veterans in the community with dementia and their family caregivers METHOD: – Separate, individual, one time only, 60-90 minute interviews – Digital audio recordings of interview – used to extract qualitative themes – Intentionally broad question guide; particularly for initial question: “Are there things you could use help with now?” ANALYSES (ongoing): – 2 independent coders analyzing for emergent themes by separately listening to the digitally recorded interviews (lower-resource method to examine gross overall themes rather than micro-coding) – Observational, theoretical, methodological notes (memos) extracted separately for Veterans and caregivers – Additional interviews will be scheduled if saturation is not achieved as analyses are finalized

13. 13 Participants (N = 30) 12 Veterans with Dementia – 76.5 years old (Range 63-83) – All men – 92% Non-Hispanic White – 8% Black/African American – MOCA scores = mild to moderate levels of impairment Range 9-28 M = 16.1, SD = 5.6 18 Family Caregivers – 70.9 years old (Range 57-82) – All women – 89% wives; 11% daughters – 83% Non-Hispanic White – 17% Black/African American CDA-1: Outpatient Needs Assessment (ONA) Qualitative Interviews with Veterans with Dementia and their Caregivers

14. 14 RESULTS: 1.Social Isolation (V & CGs) - “I isolate myself sometimes – when you talk to people and don’t have anything to say – they think you are crazy.” - Veteran with Mild Vascular Dementia Family/friends live far away or unavailable Transportation limitations Unavailability for someone to watch loved one (e.g., Bible study, bridge, etc.) 2.Anxiety and/or Depression (V & CGs) Generalized anxiety, specific fears Depressed mood requiring medication 3. Chronic Pain (V & CGs) He hurts every day, but he doesn’t like to take the pain medicines… they [doctors] have said there isn’t anything they can do for it.” – Caregiver CG noted lower tolerance for CRs behaviors when she was in pain 4. Sleep disturbances and feeling tired (V & CGs) – trouble falling asleep, staying asleep 5. Household Maintenance (V & CGs) – cleaning, meal preparation, mowing yard, etc. CDA-1: Outpatient Needs Assessment (ONA) Qualitative Interviews with Veterans with Dementia and their Caregivers

15. 15 CDA-1: Outpatient Needs Assessment (ONA) Qualitative Interviews with Veterans with Dementia and their Caregivers RESULTS (continued) 6. Strained relationships and shifting roles (CGs) Hostility/frustration associated with daily care (arguments over bathing) Loss of alone time (i.e., “He goes everywhere that I go”), Reduced meaningful communication, and changes in the relationship (e.g., “things are different now”) Shared hobbies and positive memories were nearly exclusively discussed in the past-tense without hope for resuming them in the future. 7. Staying Positive (CGs) Avoidance of distressing topics (e.g., not being able to provide care at home; “I don’t like to think that way”) Humor as a way of coping with loss. – EX: one CG described that her husband is no longer able to dress independently, but noted that when he puts his clothes on backwards the couple jokes that she must have taken them out of the wash that way. CR: “We try to make fun of everything – it’s better to laugh than cry.”

16. TELEPHONE ASSISTED DEMENTIA OUTREACH PROGRAM (TADO) The CLINICAL GRANT: Funded by the Office of Rural Health, Hilgeman (Program Lead); FY13-FY15 (10/2012 –09/2015); TDC: $625,034

17. 17 708 outpatient veterans with a primary diagnosis of dementia utilized services from the TVAMC in FY2010. 2/3 (N = 459; 64.8%) were classified as living in rural areas, with an additional N = 21 (3%) of unknown rural classification. 4,114 outpatient “visits” (appointments) across sixty different clinics. – Mean = 5.81 (mode = 1; median = 3; range = 1-57) TADO Proposal Development / Justification: Tuscaloosa VA’s Clinical Service Data for FY2010 “Visit” Frequency by Clinic (N = 4114) ClinicN% Home Based Primary Care 117629 Telephone Contacts82820 Primary Care74718 Psychiatry / Social Work / Psychology 60315 Pharmacy3097 Neuropsychology Assmt. 2406 Miscellaneous 1253 Physical Therapy / Rehab 862

18. 18 The Alabama Veteran Rural Health Initiative (Lori Davis, MD, Program Lead) was noticing an important pattern: Previously unenrolled (or those who had not used VA in 2+ years) Nearly 40% of the 203 Veterans (M = 55 years old) screened positive for probable neurocognitive deficits such as dementia (on the Montreal Cognitive Assessment, MoCA using the lower Southeastern cutoff score, 24/30) Obvious implications for ability to navigate the system. TADO Proposal Development / Justification: Unenrolled Veterans from the Alabama Veterans Rural Health Initiative (AVRHI) Davis et al, 2011; Hilgeman et al. 2014

19. 19 TADO Proposal Development – Goal: To provide individualized, evidence-based, telephone-delivered dementia care coordination services and psychosocial support to: Distressed Veterans with dementia, Caregivers of Veterans with dementia, and Veterans who are serving as caregivers for persons with dementia. – Identified 2 established interventions that were ripe for translation to this clinical population (and that had room for additional research / translation work for future grant proposals) Care Consultation (Bass, Kunik, Snow, et al) Preventing Aggression in Veterans with Dementia (PAVeD, Kunik, Snow, et al) Hilgeman (PI) FY13, FY14, FY15

20. 20 Evidence-based, standardized protocol for delivering care to an older adult with a chronic illness (primarily dementia) and their family caregiver. Dates back to 1997 Recognized as an evidence-based practice by the Agency for Healthcare & Research and the Rosalynn Carter Institute for Caregiving Translated across multiple community and healthcare settings Tested in an RCT in the VA as the Partners in Dementia Care Project (2006-2011) Compared to controls, intervention dyads who have received Care Consultation have: – Reduced depression, reduced unmet needs, less care-related strain, increased satisfaction with care, reduced NH/ALF admissions, and reduced hospital readmissions. – People with dementia have also reported less embarrassment, social isolation, and less difficulty coping with memory problems. Table 1. Key Features of Care Consultation Care consultation: 1. Empowers clients to manage care and decision-making more effectively. 2. Finds simple & practical solutions that are not overwhelming or confusing. 3. Helps clients find services and understand benefits/insurance. 4. Facilitates effective communication with doctors and other healthcare providers. 5. Sustains a long-term relationship with clients. 6. Is both standardized and personalized. 7. Focuses on preventing crises by helping clients prepare for change and prepare for the future. 8. Encourages collaboration between health care systems and community partners (either formally in a partnered model or informally). TADO Intervention: Care Consultation – a telephone-based coaching and psychosocial support intervention Bass et al. 2003; Clark et al., 2004; Clark et al., 2005; Judge et al., 2011; Bass et al., 2012

21. TADO Intervention guided by CCIS: Microsoft Access-based System

24. TADO Intervention guided by CCIS: Summary & Fidelity Reports

25. TADO is Funded! Lets start a New Clinic (What does that even mean? hint: there are a lot of forms) Funding (Spend plans, obligating money, contracting, monthly reports) Hiring 3 new FTE Staff (SW Chief as Clinical Partner, HR, Position Descriptions) Logistics (note titles, electronic consult in the EHR/CPRS, stop codes, mapping, workload credit, “clinic hours”, space/offices, computers) Develop Clinic Procedures (note templates, documentation, assessment schedule) Staff Training, Getting Referrals (manualized treatment, low hanging fruit) Enroll First Family Develop TVAMC Steering Committee Meetings with local / national Research Mentors March 2012 Proposal Submitted to ORH March 2013 Start Patient Care

26. 26 2 SW, 1 Psychologist, & Interns 185 Referred for Services (in first 16 months) 115 Enrolled in Services – (exclusions due to urban residence or no memory-related diagnoses) 74 currently Engaged/Enrolled Who is the Veteran? – 90% Care Receiver Only – 7% Caregiver Only – 3% both CG and CR Who is the Caregiver? 61.3% Wife 1.8% Husband 15.3% Daughter/Step- daughter 7.2% Son/Step-son 2.7% Brother/Sister 2.7% Other 2.7% No caregiver identified 1.8% Niece 1% Daughter-in-law 1% Significant Other TADO Caregiver & Care Recipient Demographics

27. 27 CR Race/Ethnicity – 68.1% White/Caucasian – 23.9% Black/African American – 8% Missing/Unknown Age – Care Recipient Mean = 77.7 years (SD = 9.7) – Caregiver Mean = 62.6 years (SD = 10.4) Gender – 93% Male CRs – 89% Female CGs Care Recipient's Marital Status: – 76% Married – 11.5% Widowed – 10.6% Divorced/Separated – 1% Single/Never Married TADO Caregiver & Care Recipient Demographics

28. 28 TADO Care Recipients (Patients) Variety of dementia-related disorders are represented across multiple stages of illness Note. “Other” includes Memory Loss, Parkinson’s Dementia, and others who have screened positive on a screener like the MMSE or SLUMS.

29. 29 TADO Program Evaluation Goal 1. Improve Access For Rural Patients Increased Access to Dementia Specialty Care: – Referrals from 23 Providers/Clinics – Veterans from 27 Counties in Alabama Decreased Transportation Burden and Costs – 505 Phone Sessions (94% of contacts); 30 in person session (6%) – 55,033 Miles saved families by doing phone sessions ~ $9,410.00 in gas money – $29,174 Unissued Travel Reimbursement (hospital savings)

30. 30 TADO Program Evaluation Goal 2. Identify & Address Unmet Needs Most Frequent Areas of Unmet Needs at the Initial Assessment 1.Arranging Services (31.3% expressed concern; discussed by 51.3%) 2.CG Emotional and Physical Health Strain (28.8%; 51.4%) 3.CR’s Memory Problems & Difficult Behaviors (28.7%; 47.8%) 4.CG’s Anxiety (24.3%; 32.4%) 5.CR’s Medications (23.5%; 52.2%) 6.CR’s Memory Problems Diagnosis (22.6%; 51.3%) 7.Quality of Informal Support (20.9%; 37.4%) 8.CG’s Capacity to Provide Care (21.7%; 46.8%) 9.CR’s Sleep (20%; 31.3%) 10.CR’s Anxiety (18.3%, 38.3%) 11.CR’s Depression (17.4%; 43.5%) 12.Financial Concerns (17.4%; 38.3%) % indicates how often this area was “triggered” as an area of concern for the family or person with dementia

31. 31 TADO Program Evaluation: Goal 3. Reduce Distress – Stress How much stress are you experiencing in the past 2 weeks? Rated 1-10, with 10 being the most stress imaginable Sample Case – Mr. & Mrs. X, 69 and 67 yrs old; Dementia NOS

32. 32 Caregiver Zarit Burden Inventory – Ex: Do you feel that because of the time you spend with (CR) that you don’t have enough time for yourself? CR Geriatric Depression Scale – Ex: Is your spouse/relative basically satisfied with his/her life? TADO Program Evaluation: Goal 3. Reduce Distress – CR Depression & CG Burden

33. 33 20 Item Satisfaction Survey: 1.Giving you or your family members useful information. 2.Explaining things to you in a way that you can understand. 3.Helping you and your family get the needed help. 4.Caring about you as a person. 5.Including you in planning for your care 6.Helping you or your family get the needed help. Results Across All Items: 84.5% of items rated “Excellent” 14.95% of items rated “Good” 0.54% of items rated “Fair” 0.0% of items rated “Poor” Qualitative Data Globally Positive: “I look forward to your calls. I can talk and not feel embarrassed and you help me. I would not want to go through what I’m going through without you. I don’t feel like I’m alone.” “You brighten my day. You encourage me and give me hope again.” TADO Program Evaluation: Goal 4. Achieve High Satisfaction with TADO

34. WHERE WE ARE NOW… PLANNING FOR THE NEXT RESEARCH GRANT & SUSTAINMENT OF TADO Clinical ORH Funding (2012-2015) Research: CDA1 Funded (2013-2015) Research: CDA2 Funding (Hopefully - 2015- 2020) Clinical: Transition TADO to Permanent Clinic (Hopefully TVAMC Funded) Future Research Grants

35. 35 TADO Observations – Informing CDA-2 Research Grant Proposal Rich Clinical Cases with demonstrated improvement over 6-12 months Lots of information on Identified Needs + Complements CDA1 Qualitative Results Demonstration of feasibility, acceptability, need, relatively low cost intervention delivery (telephone, SW) Clinical Observations that guide next research steps: – Many of the Veterans / Caregivers have extremely complex caregiving contexts – Substance abuse, marital distress/discord, paralyzing grief, PTSD/MH comorbidities – Care Consultation alone (coaching, support model) not equipped to address these issues Original studies referred about 20% for additional MH services TADO – 56% estimated to need additional psychotherapy elements “Clinical laboratory” for intervention development (i.e., developing/modifying targeted counseling components that can be delivered over the phone to address those in higher distress) – PIPAC dissertation intervention, PAVeD modules, etc.

36. 36 Career Development Award (CDA2) – Resubmission in December 2014 Baseline/Screening (identify “distressed” dyads) Begin 3 months of Care Consultation Identify Non- Responders Continue in CC CC+C Care Consultation + Counseling Responders Refer to Clinical TADO VA CDA-2 is a 5 year Mentored Award (similar to K01) Initial submission in June 2014 – good score, not funded Second submission planned for December 2014 Mentoring Team: Davis, Snow, Allen, Kunik, + Bass (BRI CC developer) Aim 1: Develop Care Consultation + Counseling Intervention (CC+C) Manual Aim 2: Conduct initial pilot to determine if CC+C is more effective than CC alone

37. 37 Sustaining TADO – Where the Clinical & Research Elements Meet Policy, Legislation, & Funding Issues Many benefits to Care Consultation (guided by CCIS) – Evidence-based, ideal for remote delivery, can be implemented now without additional infrastructure – Computerized system guides care delivery through a clinical tool that aids fidelity to original research protocols; Fidelity and summary reports at the click of a radial button. – Coaching and support model can be implemented by bachelors prepared SWs, nurses, or other trained staff. – Stand alone program is not a security risk (i.e., Access does not communicate remotely, all stored on a secured server within the system firewall, does not interface with electronic health record system) Challenges to future implementation – Problem of dual record keeping, dual effort in health care settings with electronic records – for full integration CCIS will need to communicate with electronic health records (i.e., produce a progress note). – Standards for documenting caregiver support in Veteran’s medical record are not yet global (some clinical judgment and potential for ethical grey areas). – TELEPHONE SERVICES ARE NOT BILLABLE…

38. 38 Is TADO Telehealth? VA has a clear commitment to Telehealth, which shares goals with programs like a Care Consultation approach for dementia. Telephone-based programs like TADO do not fit in existing definitions. – Telephone-based services are not widely billable (ATA review indicates only 2 states) – Encouraged to modify for clinical video telehealth in the home VA Office of Telehealth – Three primary areas of services: – Clinical Video Telehealth – video conferencing to connect providers with Veterans Typically from a VA medical Center to a smaller Community- Based Outpatient Clinic – Home Telehealth – home monitoring devices such as “health buddies” that communicate data back to providers – Store-and-Forward - storing and forwarding images, video, and sound files from where the Veteran lives/receives care to where the specialist is located Sustaining TADO – Where the Clinical & Research Elements Meet Policy, Legislation, & Funding Issues US Government Accountability Office (GAO-030487, 2003)

39. 39 Can TADO become telehealth? Evolving telecommunications technology may offer a solution for the access/translation problem. However, internet use / availability in the homes of some groups is still low – “Digital Divide” – SES and demographic divide between users and non-users (older adults – particularly those in rural areas and low SES urban areas) EX: Internet Use among Rural Alabama Veterans (N=203) – 81.3% < 50 yrs – 44.3% between 50-64 yrs – 35.5% of 65+ years Indicates telephone delivery may still be the best option for some groups. Sustaining TADO – Where the Clinical & Research Elements Meet Policy, Legislation, & Funding Issues Source: The State Broadband Initiative supported by the Alabama Department of Economic and Community Affairs and the National Telecommunicaitons and Information Administration (NTIA) Broadband Service Map of Gaps (light areas indicate little to no availability) Morell et al., 2010; Allen et al., 2013; Hilgeman et al., 2014

40. 40 CONCLUSIONS: Bringing it All Together - Big Picture / Future Goal Establish Research Independence through VA & Other External Funding Mechanisms (NIH, PCORI, foundation, pharmaceutical industry funding, etc.) – CDA1 – check! – CDA2 – resubmitting in December 2014 – Establish strong collaborations / Co-I opportunities and Non-VA funding through the Non-Profit TREAC (Tuscaloosa Research Education and Advancement Corporation) – Investigator Initiated Research (VA IIRs / Merit) Grants & NIH R01s Establish Memory and Aging Care Clinic at the TVAMC (long term-home for TADO) – Proposal currently in development (interdisciplinary clinic with Psychiatry, Neuropsychology, Nursing, and SW as core disciplines) Would make TADO Staff permanent staff (supported by TVAMC, not soft money from ORH) Would offer long-term clinical/research partnership for intervention development, translation research, and recruitment of other research studies.

41. 41 TADO Clinic Team: Amy Mitchell, MSW Kate Ball, LICSW, PIP Tracy Clements, Whitney Gay, Dedria Smith, Beverly Whitfield Interns: Heather Talbert, etc. Funders: Office of Rural Health VA Rehabilitation Research & Development Research Mentors & Key Partners (TADO Steering Committee and Co-Investigators): Scott Martin, Chief of Social Work Services Dr. Lori Davis, Chief of Research & Development Service Dr. Lynn Snow, Research Clinical Psychologist Dr. Rebecca Allen, UA Psychologist Dr. Mark Kunik, BCM & Houston MEDVAMC Dr. David Bass, Benjamin Rose Institute Dr. Avi Nichani, Acting Chief of GEC / HBPC Geriatrician Dr. Sylvia Colon-Lindsey, Geriatric Psychiatrist Kristin Pettey, VISN 7 Rural Health Coordinator Acknowledgments

42. 42 Selected References Yaffe K, Vittinghoff E, Lindquist K, Barnes D, Covinsky KE, Neylan T, Kluse M, Marmar C. Posttraumatic stress disorder and risk of dementia among US veterans. Arch Gen Psychiatry. 2010 Jun;67(6):608-13. Krishnan LL, Peternen NJ, Snow AL, Cullye JA, Schulz PE, Graham DP, Morgan RO, Bruan U, Moffett ML, Yu HJ, Kunik ME. (2005) Prevalence of dementia among Veterans Affairs Medical Care systems users. Dementia and Geriatric Cogntive Disorders 20:245-253. IOM. (2008) The Institute of Medicine estimates that a majority of older adults in the coming decades will have at least one chronic condition and access the health care system more than other generations. Alzheimer's Association. (2009) Characteristics, Costs and Health Service Use for Medicare Beneficiaries with a Dementia Diagnosis: Report 1: Medicare Current Beneficiary Survey. Prepared under contract by Bynum J, Dartmouth Institute for Health Policy and Clinical Care, Center for Health Policy Research. McCarten JR, Anderson P, Kuskowski MA, McPherson SE, Borson S. (2011) Screening for Cognitive Impairment in an Elderly Veteran Population: Acceptability and Results Using Different Versions of the Mini-Cog. Journal of the American Geriatrics Society 59:309–313. S. 1963--111th Congress: Caregivers and Veterans Omnibus Health Services Act of 2010. (2009) In GovTrack.us (database of federal legislation). http://www.govtrack.us/congress/bill.xpd?bill=s111-1963. Retrieved May 10, 2011. http://www.govtrack.us/congress/bill.xpd?bill=s111-1963 Department of Veterans Affairs: Public and Intergovernmental Affairs press release. VA Partners with Easter Seals to Train Family Caregivers of Wounded Warriors. Press release on May 9, 2011. http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2095. Retrieved 05/09/2011.http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2095 Algase DL, Beck C, Kolanowski A, Whall A, Berent S, Richards K, et al. (1996) Need-driven dementia compromised behavior: An alternative view of disruptive behavior. Am Jour of Alz Dis 11:10-19. Hebert R, Dubois MF, Wolfson C, Chambers L, Cohen C. (2001) Factors associated with long-term institutionalization of older people with dementia: Data from the Canadian study of health and aging. Journal of Gerontology, medical sciences 56A:11:M693-699. Judge, K. S., Bass, D. M., Snow, A. L., Wilson, N. L., Morgan, R., Looman, W. J.,... & Kunik, M. E. (2011). Partners in dementia care: A care coordination intervention for individuals with dementia and their family caregivers. The Gerontologist, 51(2), 261-272. Hilgeman, M.M., Mahaney-Price, A.F., Stanton, M.P., McNeal, S.F., Pettey, K.M., Tabb, K.D., Litaker, M.S., Parmelee, P., Hamner, K., Martin, M.Y., Hawn, M., Kertesz, S.G., Davis, L.L. and the Alabama Veterans Rural Health Initiative Steering Committee. (in press). Alabama Veterans Rural Health Initiative: A Pilot Study of Enhanced Community Outreach in Rural Areas. Journal of Rural Health. Davis, L. L., Kertesz, S. G., Mahaney-Price, A. F., Martin, M. Y., Tabb, K., Pettey, K. M., McNeal, S.F., Granstaff, U. S., Hamner, K., Powell, M.P., Hilgeman, M. M., Snow, A. L., Stanton, M., Parmelee, P., Litaker, M., & Hawn, M. T. (2011). Alabama veterans rural health initiative: A preliminary evaluation of unmet health care needs. Journal of Rural Social Sciences, 26(3), 74-100. http://www.ag.auburn.edu/auxiliary/srsa/pages/Articles/JRSS%202011%2026%203%2014-31.pdf http://www.ag.auburn.edu/auxiliary/srsa/pages/Articles/JRSS%202011%2026%203%2014-31.pdf

43. Thank You! Questions / Comments For More Information Contact: Michelle.Hilgeman@va.gov