Improving Dementia Care in the CHA House Calls Program 

Serena Chao

My project is focused on improving care provided by the CHA House Calls team to patients with dementia, their family members, and their caregivers. My main goals are to:  1) enhance health care provider’s management of demented patients’ behavioral symptoms and progressive clinical decline; 2) alleviate caregiver stress by systematically connecting families and caregivers with appropriate community services; and 3) reduce the risk of demented patients receiving harmful aggressive medical interventions that have little hope of improving quality or quantity of life through engagement of all team members—including families and caregivers—in the creation of shared, realistic goals of care. I plan to target three separate groups for dementia-related education: 1) patients and their families/caregivers; 2) House Calls clinical staff; and 3) staff at the two assisted living facilities operated by the VNA of Eastern Massachusetts (in Cambridge and Somerville). Potential outcome measures would be reduction in preventable ER visits and hospitalizations and decreased family/caregiver self-rated stress. Process measures would include increased referrals to community services, increased percentage of patients with DNR/DNI status on completed MOLST orders, and increased referrals to palliative care and/or hospice depending on the patient’s needs, preferences, and stage of disease.