Caring for Older Adults and Caregivers at Home (COACH) is an innovative care coordination program of the Durham Veteran's Affairs Medical Center in Durham, North Carolina, that provides home-based dementia care and caregiver support for individuals with dementia and their family caregivers, including attention to behavioral symptoms, functional impairment, and home safety, on a consultation basis. The objectives of this study were to describe the COACH program in its first 2 years of operation, assess alignment of program components with quality measures, report characteristics of program participants, and compare rates of placement outside the home with those of a nontreatment comparison group using a retrospective cohort design. Participants were community-dwelling individuals with dementia aged 65 and older who received primary care in the medical center's outpatient clinics and their family caregivers, who were enrolled as dyads (n = 133), and a control group of dyads who were referred to the program and met clinical eligibility criteria but did not enroll (n = 29). Measures included alignment with Dementia Management Quality Measures and time to placement outside the home during 12 months of follow-up after referral to COACH. Results of the evaluation demonstrated that COACH aligns with nine of 10 clinical process measures identified using quality measures and that COACH delivers several other valuable services to enhance care. Mean time to placement outside the home was 29.6 ± 14.3 weeks for both groups (P = .99). The present study demonstrates the successful implementation of a home-based care coordination intervention for persons with dementia and their family caregivers that is strongly aligned with quality measures.

Limited information is available about the rates and risk correlates of socioemotional/behavioral problems in young children in pediatric primary care settings serving low-income families. Our objective was to determine rates of clinically significant socioemotional/behavior problems in 12- to 48-month-olds from low-income families and identify associations between problems and individual and cumulative demographic and psychosocial risks. In this study, 378 Spanish- and English-speaking mothers attending a pediatric primary care practice serving low-income families were surveyed before well-child visits to assess socioemotional/behavioral problems (Brief Infant-Toddler Social-Emotional Assessment; M.J. Briggs-Gowan & A.S. Carter, ) and psychosocial and demographic risks (e.g., unemployment, low social support) (Parent Risk Questionnaire; D.I. Lowell, A.S. Carter, L. Godoy, B. Paulicin, & M.J. Briggs-Gowan, ). We found that 19.8% of children had clinically significant problems, and 53.2% experienced one or more psychosocial risks. Clinically significant socioemotional/behavioral problems were modestly to strongly associated with individual psychosocial risks, with the strongest associations with parental medical problems, parent depression/anxiety, and extreme parental distress, Adjusted Relative Risk (ARR) = 4.8-6.6, p < .0001. Cumulative demographic and psychosocial risk were uniquely associated with clinically significant problems, particularly among children experiencing three to four psychosocial risks, ARR = 3.0-11.6, p < .05. Psychosocial risks affect the majority of low-income families with young children, with a steep increase in likelihood of clinically significant socioemotional/behavioral problems as risks accumulate, underscoring the need to address both socioemotional/behavioral issues and psychosocial risk in young children.

Since 2010, the Veterans Health Administration has initiated a home-based Caring for Older Adults and Caregivers at Home (COACH) program to provide clinical support to dementia patients and family caregivers. But its impact on health care utilization and costs is unknown. We compared 354 COACH care recipients with a propensity score weighted comparison group of 9,857 community-dwelling Veterans during fiscal years 2010-2015. In 1-year follow-up, COACH program was associated with a lower rate of long-term nursing home placement (average treatment effect on the treated [ATT] –3%; p = .01). The program increased utilization of emergency services (ATT 6%; p = .01), hospitals (ATT 10%; p < .001), and personal care services (ATT 31%; p < .001). Health care costs were also significantly increased. Improved access to services may have enabled COACH Veterans to stay at home longer. As one of Veterans Health Administration’s top priorities to expand caregiver assistance programs, COACH seems to be a promising model for a nationwide implementation.

: Parent worry regarding social-emotional/behavioral issues may be a useful adjunct to developmental surveillance, as it identifies children with the most significant behavioral and social-emotional problems. However, as a screening method to identify all young children with social-emotional problems, parent worry does not currently achieve acceptable classification.