Optimising functional and social independence and safety of older people living with dementia in care homes: Implementation Research of Interdisciplinary Care Home-bAsed Reablement Program (I-CHARP)

The results of the recent pragmatic randomized control trial (RCT) of the Interdisciplinary Home-bAsed Reablement Program (I-HARP) have shown that a structured, evidence based and person-centred rehabilitation program delivered in the community improved daily functioning of people with mild dementia, enabling them to live longer at home. This NHMRC partnership project, Optimising functional independence of older persons with dementia: Implementation and evaluation of the Interdisciplinary Care Home-bAsed Reablement Program (I-CHARP), builds on I-HARP in order to transfer the program logic of I-HARP to residential aged care settings. I-CHARP sessions delivered over 4-6 months by the I-CHARP clinicians (registered nurses, RNs, and occupational therapists, OTs) will include: 1) An initial comprehensive assessment (in the 1st session) performed by a) an OT for cognitive and functional abilities, strength, balance and home safety risks, and b) an RN for the medication regimen, pain, incontinence, depression and other chronic disease management issues. A case conference (30 min to 1 hour between the I-CHARP RN and OT) will take place soon after the 1st session (within a week) to discuss potential goals and strategies that the resident may consider. 2) Subsequent interdisciplinary, tailored care planning to enhance self-care ability using person-centred goal setting. I-CHARP clinicians will work closely with the person with dementia and the care staff to help them identify the goals and action strategies that the client aims to achieve in the following 3 months. 3) Implementation of the plan through a series of one-on-one sessions, including cognitive rehabilitation, combining compensatory (e.g. calendars, diaries, reminders) and restorative strategies (e.g. mnemonics, semantic association, spaced retrieval), energy conservation and task simplification strategies, balance and strength exercises, pain relief, anxiety and depression management, problem solving, medication simplification/adherence training, and minor home alterations and assistive devices. 4) I-CHARP clinicians (i.e. RNs and OTs) are employed by the partner aged care providers and will be trained and supervised by the I-CHARP trainers and CIs and AIs with rehabilitation expertise. Training involves the principles of I-CHARP, key rehabilitation interventions and strategies (e.g., comprehensive assessments, cognitive rehabilitation, motivational interviewing, goal settings, person centred care, exercise, clinical management, etc.), as well as roles and responsibilities as I-CHARP clinicians. The one off interactive three day training will be delivered in person or via online over three days (RNs and OTs trained together for 2 days and one additional day for RNs). Ongoing clinical supervision will be provided by rehabilitation experts (up to 10 sessions of ~30 min per session over the intervention period). Training will take place immediately before the intervention (within 4 weeks of the training the intervention will commence) 5) When the OT in-person session is not possible (due to lack of availability of local OT) the intervention is carried out via video telehealth conference. The method of the intervention delivery and any adjustments made will be recorded and monitored for fidelity. 6) The delivery of the I-CHARP intervention is supported through the deployment of an implementation strategy – REACH Network (a web portal that supports information and a community of practice for I-CHARP clinicians and management of intervention sites). The I-CHARP RN will act as a case coordinator while working closely with the I-CHARP OT; The I-CHARP RN will be responsible for engaging and supporting other care staff and regular visitors closely involved in care (working as partner/collaborator in care). For example, residents reaching I-CHARP will participate in setting goals and strategies and for them to act on those strategies they are likely to require ongoing prompting and support (e.g., strength and balance exercises, using a technology device to enhance social and/or cognitive activities, etc.) The delivery model has been co-designed with the partner organisations to ensure staff employed by the partner organisations are primary sources of the delivery, while making an allowance for the fact allied health services often require engagement of external services. Each partner organisation formed a co-design group and they were presented with the I-HARP model and invited to provide feedback. Senior management of the partner organisations are members of a consortium to allow for cross organisation discussion and consensus. Monthly co-design groups and additional consortium groups took place to discuss their existing models of care and ways to incorporate/integrate I-CHARP, with a particular focus on staffing and other resource implications. The co-design process took place over 6 months, 4 months prior to the delivery of the intervention. I-CHARP uses the same principles and procedures as I-HARP and integrated into residential aged care services as a model of care. The different aspects of I-CHARP from I-HARP include: 1) OT sessions can be delivered via telehealth and all OT sessions are supported by RN; 2) minor home modification and/or assistive devices to the value of up to $400; 3) the frequency and length of the sessions (4-5 OT full sessions, 8-9 RN full sessions, plus ~8 RN short sessions of 15 min which can be delegated to personal care workers, PCW). Flexibility of the intervals and the length of the sessions is emphasised; 4) I-CHARP has no specific carer support sessions and instead engages the whole of the participating care home staff, managers and regular visitors; and 5) Same as I-HARP, up to 4 sessions with other allied health professionals will be supported per resident as part of I-CHARP.