Supporting Veterans with dementia to remain in the community: strategies used in 12 Veterans Health Administration programs

Abstract

The Veterans Health Administration (VA) provides services to growing numbers of Veterans with dementIa, individuals at heightened risk for hospitalizations and nursing home placement. Beginning in 2010, the VA funded 12 innovative pilot programs to improve dementia care and help Veterans remain at home. We conducted a retrospective qualitative analysis of program materials and interviews with physicians, nurses, social workers, and other personnel (n = 33) to understand the strategies these programs adopted. Interviews were conducted every 6 months between 2010–2013 (4–5 interviews per program) and focused on factors affecting program design and implementation, challenges, and strategies to reduce hospitalizations and nursing home placements. Programs varied considerably yet shared three overarching strategies to improve dementia care: involving and supporting family caregivers; engaging interdisciplinary teams; and improving coordination with other healthcare providers. Our results highlight the importance of adapting common dementia care strategies based on the local context and needs of individuals served.

Introduction

The Veterans Health Administration (VA) is the largest integrated healthcare system in the United States (US), providing services to approximately 9 million Veterans. More than half of VA patients are age 65 or over and nearly 1.2 million are at least age 85. (U.S. Department of Veterans Affairs) Age is the single greatest risk for the development of dementia, a group of conditions characterized by impairment in at least one area of cognitive function (e.g., executive function, memory, learning). (Alzheimer’s disease facts and figures, 2020) As the Veteran population rapidly ages, the number of VA patients living with dementia is expected to increase from 409,000 to 500,000 by 2033. (U.S. Department of Veterans Affairs, Veterans Health Administration, 2019a) These projections are consistent with estimates for the general US population, where the number of persons living with dementia is expected to double over the next 30 years. (2020Alzheimer’s disease facts and figures, 2020) Finding ways to effectively provide care to the growing numbers of Veterans with dementia is a critical VA and national priority. (2020Alzheimer’s disease facts and figures, 2020; Beane, Callahan, Stone, & Zimmerman, 2021; U.S. Department of Veterans Affairs, Veterans Health Administration, 2019a)

Among older adults, dementia is the primary cause of “disability and dependency,” (World Health Organization, Dementia, 2020) resulting in increased need for assistance from others to conduct basic daily activities. Individuals with dementia experience a range of care needs, which change as the disease progresses. In earlier stages of dementia, the need for assistance may be relatively low (e.g., reminders to take medications or help managing finances). As dementia progresses, the need for assistance tends to increase and expand to include more fundamental activities of daily living, such as bathing, dressing, or eating. Over time, the burden on families increases, often leading to considerable stress for family caregivers, (AARP and National Alliance for Caregiving; Qualls & Williams, 2013) and need for increased support to help families provide care. Yet, families often lack information to help them navigate care systems, explore available services, and manage the behavioral symptoms the person with dementia may experience, such as wandering, increased irritability or aggression, and isolation or withdrawal. (2020Alzheimer’s disease facts and figures, 2020; National Academies of Sciences, Engineering, and Medicine, 2016) These challenges can be magnified by fragmented care systems, which often lack structures and processes to ensure good communication and coordination with patients and families, as well as between healthcare providers. (Cebul, Rebitzer, Taylor, & Votruba, 2008; Elhauge, 2010) Consequently, persons living with dementia experience increased risk for adverse outcomes, including hospitalizations, nursing home placement, and poor experiences with care. (2020Alzheimer’s disease facts and figures, 2020)

For many years, the VA has been a leader in healthcare for older adults in the US. Beginning in the 1970s, the VA led the establishment of robust interprofessional training programs in geriatrics and innovative models of non-institutional care. (Edes et al., 2014; Rasin-Waters, Abel, Kearney, & Zeiss, 2018) Over the past 50 years, the VA has developed a robust continuum of geriatrics and extended care programs to meet the needs of older Veterans in ambulatory, inpatient, home- and community-based, and facility settings. Examples include home-based primary care (subsequently expanded in the community through Medicare as “Independence at Home”), (Edes et al., 2014; Rotenberg, Kinosian, Boling, & Taler, 2018) which provides care to frail, medically complex Veterans in their own homes, and the Coordinated Transitional Care program, (Kind et al., 2016) which supports high-risk Veterans and their caregivers during transitions from the hospital back home. Primary care is the foundation of care within the VA and over the past decade, VA has transitioned to the patient-centered medical home model of primary care (Patient-Aligned Care Teams, or PACT, in the VA), with geriatrics-specialized PACT teams (Geri-PACTs) available at some sites. (Sullivan, Shin, & Adjognon et al., 2018) Although certain geriatrics-related services are available at most or all VA medical centers (e.g., home care, respite, and nursing home services), there is considerable variation in the availability of other services varies across sites. For example, approximately half of VA medical centers had specialized Geri-PACTs in 2018 and fewer than 30% had an interdisciplinary dementia or memory disorders clinic. (U.S. Department of Veterans Affairs, Veterans Health Administration, 2019b) Further, many older Veterans receive care at VA community-based outpatient clinics, where specialized geriatrics and dementia services are less available. (Pimentel et al., 2019)

As part of its ongoing commitment to continually improve care for older Veterans, the VA Office of Geriatrics and Extended Care launched a national initiative in 2010 to provide pilot funding to programs to support older Veterans at high risk for hospitalizations and nursing home placement remain in their homes and communities as they age. (Sullivan et al., 2018) The initiative, Transformation to the 21^st Century Care (hereafter referred to as the “T21 initiative”), was part of an ongoing effort to shift long-term care services from institutional to home- and community-based settings. The T21 initiative was designed to allow local VA geriatrics leaders to innovate care delivery based on their center’s existing services, priorities, and specific needs of the Veterans they served. Between 2010 and 2013, 59 distinct programs across the US were established through Phase 1 of the T21 initiative. (Sullivan et al., 2018) Twelve of these programs specifically focused on improving dementia care services. Although pilot funding for the programs launched through the T21 initiative ended in 2013, many programs were sustained beyond the pilot period. In fiscal year 2020 (10/1/19–9/31/20), over 19,000 Veterans received services through one of the programs established through the T21 initiative. In fiscal year 2021, eight of the 12 dementia programs (75%) remained active. In this paper we describe common strategies implemented through the dementia care programs and discuss implications for dementia care in the VA and other healthcare systems.

Materials and methods

This paper presents findings of a retrospective review of data from a multi-year process evaluation of the T21 initiative described above. Our review involved a secondary qualitative analysis involving data from two sources: 1) programmatic materials (e.g., program proposals and regular progress reports submitted by leaders of the dementia care programs); and 2) semi-structured individual and group interviews conducted with individuals involved in developing and implementing the dementia care programs (i.e., program leaders). The original process evaluation was conducted by investigators at the VA Boston Healthcare System. The interviews were conducted approximately every six months over the three-year pilot funding period, resulting in 57 total interviews about the dementia care programs (approximately 5 interviews per program). Interviews focused on contextual factors influencing program development; program goals, structures, and processes; challenges and facilitators to implementing the program; modifications over time; and sustainability plans. More details about the interviews and methods have been described elsewhere. (Sullivan et al., 2018)

We used a primarily deductive process to analyze the data. First, the lead author reviewed all program materials and interview data and organized information into domains and sub-categories corresponding to topics addressed in the program reports and interviews (i.e., the topics noted above). For example, the program goals domain included information about the number of Veterans the program intended to serve and targeted program outcomes. This same author then summarized findings for each domain and sub-category by program, using a template agreed upon by the research team. The summaries were reviewed by the senior member of the team [JLS], who led the original T21 initiative process evaluation and over-saw data collection, analysis, and interpretation of findings for the parent study. There was a high level of agreement between the first and senior author on program-level findings, and we achieved consensus on final findings through discussion. After finalizing the program summaries in collaboration with the senior author, the lead author developed a matrix display to compare findings by domain across the 12 programs. (Miles & Huberman, 1994) Three investigators [HD, KAO, JLS] then reviewed and discussed the overall findings, including overarching program strategies and similarities and differences in use of the strategies across programs. To enhance the validity of findings, other team members who participated in the original process evaluation, including data collection and prior analyses of the data [MHS, RLE, OLA], reviewed the results, provided feedback, and verified the “trustworthiness” of the data. (Creswell & Poth, 2017; Lincoln & Guba, 1985) NVivo qualitative software (QSR International, Inc.) was used for data management.

Results

Interview respondents included personnel involved in implementing the dementia care programs (n = 33), including physicians (n = 11), nurses (n = 9), social workers (n = 5), and other personnel (e.g., executive leader, administrative support personnel, etc.) (n = 8). Of the 12 programs, 3 served primarily rural Veterans, 1 served urban Veterans, and 8 served both rural and urban Veterans. During the initial pilot funding period, the 12 dementia care programs served 5,228 VA patients, with 140 to over 2,000 patients served per program.

Dementia care programs

All 12 programs focused on improving care for Veterans with dementia, yet they varied in their primary focus and the specific strategies used to improve dementia care. Programs fit into several broad categories, which included care management and coordination (5 programs), primary care (4 programs), and caregiver education and support (3 programs). Given the overarching goals of the T21 initiative, all programs aimed to reduce hospitalizations and nursing home placements. Other common goals included improving communication and coordination with Veterans, caregivers, and other healthcare providers; easing caregiver burden; improving Veterans’ and families’ experiences with care; and increasing internal (i.e., VA) referrals to the program for Veterans and caregivers who could benefit from the specialized dementia services. One leader explained that they had developed their program after noticing fragmentation and duplication of services for Veterans with dementia. Another leader noted that they had observed Veterans with dementia “slipping through the cracks.”

Programs varied in how they were structured. Five programs were based in longstanding clinics at VA medical centers (e.g., primary care clinics) and five programs involved interventions that were delivered in Veterans’ homes. Additionally, two programs involved interdisciplinary teams of VA healthcare providers that traveled to VA community-based outpatient clinics and non-VA adult day healthcare programs (i.e., contract adult day programs) serving VA-enrolled Veterans. Despite these differences, programs shared three common overarching strategies to improve care, including: 1) involving and supporting family caregivers; 2) engaging specialized interdisciplinary care teams; and 3) improving communication and coordination with other healthcare providers. We describe these strategies in more depth next (see also Table 1).

Table 1.

Common strategies implemented through 12 Veterans health administration dementia care programs.

Strategy	Elements of strategy	Examples of strategy
Involving and supporting family caregivers	Providing education to family caregivers Checking in with caregivers and providing support as needed	A peer support group for family caregivers begins each week with brief educational content. Family caregivers are sent regular check-in questions via a home telehealth platform. Based on their responses, program personnel facilitate additional support.
Engaging specialized interdisciplinary care teams	Establishing a core dementia care team Enlisting support of other healthcare professionals (e.g., pharmacist, psychologist) Providing support to internal (VA) primary care teams	A program nurse or social worker manages the overall program and aspects of care for participating patients. A pharmacist reviews patients’ medications and recommends dose reductions or the elimination of medications no longer needed. An interdisciplinary team of dementia care specialists visits VA outpatient primary care clinics to conduct assessments and develop care plans for patients and family caregivers.
Improving communication and coordination with other healthcare providers	Conducting outreach to VA and non-VA providers about the dementia care program Ensuring communication with other VA and non-VA providers about important aspects of patients’ care	Dementia care team members conduct outreach to clinics, support groups, and community organizations that serve Veterans. A program social worker coordinates care with local home care agencies who are involved in the patient’s care, such as after a hospital stay.

VA = Veterans Health Administration

Strategy 1: Involving and supporting family caregivers

All programs involved and supported family caregivers, with respondents often emphasizing the importance of family support to Veterans’ ability to remain at home. Several programs formally measured caregiver stress or burden. Programs used two main strategies to involve and support caregivers: education and social support. Education focused on topics relevant to caring for a person living with dementia, such as managing agitation and challenging behaviors, home safety, self-care for the caregiver, meaningful activities, and navigating end of life issues. Program personnel delivered educational content to caregivers in several ways: individually (in person or via telephone), as part of other activities (e.g., blocking off part of a regular caregiver support group meeting for education), and through online training modules. One program offered a weekly teleconference support group for caregivers, which began with 20–30 minutes of educational content, followed by time for caregivers to share their experiences and ask questions. Respondents in several programs said many caregivers had difficulty leaving home to participate in activities like support groups. To address this barrier, a program that served large numbers of rural Veterans and caregivers developed online content with information related to addressing common caregiving challenges.

Strategies to provide support to caregivers included formal support groups, establishing a dedicated helpline for caregivers, and providing caregivers with individual counseling sessions with program personnel. In one program, questions were sent regularly to family caregivers via a home telehealth platform to assess how they were coping with daily aspects of caregiving. If a caregiver indicated they were struggling, personnel followed up to assess their specific needs and determine if additional services for the Veteran or caregiver were needed. In another program, an interdisciplinary team of VA healthcare providers collaborated with caregivers to establish a support plan based on the caregiver’s individual needs. Several programs included home visits by program staff or telehealth (such as home blood pressure checks) to ease the burden on caregivers by reducing the need to travel for in-person appointments.

Strategy 2: Engaging specialized interdisciplinary care teams

Programs used specialized, interdisciplinary teams to improve care. Respondents often discussed the importance of using an interdisciplinary approach, given the social and medical complexity of many of the Veterans they were serving. One provider noticed the, “dire, certainly complex situations,” some of their patients faced and explained that without interdisciplinary collaboration, important issues affecting a Veteran’s quality of life (e.g., nutrition, end of life discussions, transportation challenges) could go unaddressed.

Although all programs used an interdisciplinary approach to provide care, programs differed in how they accomplished this collaboration. Most programs included a registered nurse and social worker, one or both of whom managed the overall program and served as care coordinator for participating Veterans. Geriatricians (physicians with specialized expertise in the care of older adults) were also often involved in the core dementia care team. Depending on the focus and scope of the specific program, teams also included other healthcare providers, such as a pharmacist, psychologist, psychiatrist, neurologist, nutritionist, and occupational or physical therapist. These providers usually played a part-time consultative role, providing input to core dementia team members on care for specific Veterans. In several programs, pharmacists helped with medication management by reviewing Veterans’ medications and recommending changes, such as dose reductions or the elimination of unnecessary medications. In another program, an occupational therapist assessed Veterans’ functional abilities, adaptive equipment needs, and conducted home and driving safety evaluations. Core team members typically maintained daily contact, with the broader interdisciplinary team meeting weekly or biweekly, with additional consultations as needed. In several programs, respondents said being co-located with other team members facilitated collaboration and shared decision-making.

Several programs grew out of an existing dementia care clinic, at sites where expanded services were needed. For example, one program involved a “satellite” interdisciplinary team (including a geriatrician, psychologist, pharmacist, nurse, and social worker) who visited VA primary care clinics. During visits, the dementia care team completed physical exams, caregiver interviews, neuropsychological testing, and medication reviews. They also worked with Veterans’ primary care team to develop comprehensive care plans. In another program, the dementia care team took on care management for the most complex primary care Veterans with dementia. In several programs, individual healthcare providers completed assessments with Veterans and caregivers individually (e.g., consecutively over a day-long clinic visit), then collaborated to develop care plans based on the Veteran’s and caregiver’s unique care needs.

Strategy 3: Improving communication and coordination with other healthcare providers

Another important focus was improving communication and coordination with other healthcare providers. For most programs, a key part of this involved conducting outreach to other VA programs and services to raise awareness about the dementia care program. A common goal was generating referrals of Veterans and caregivers who could benefit from the program’s services. Common outreach targets included VA primary care clinics (including community-based outreach clinics), VA and community caregiver support groups, and short-term rehabilitation units where Veterans received care.

Another component of the programs involved strengthening care coordination with other healthcare providers. The dementia program’s care manager (a nurse or social worker) would typically communicate relevant information to the Veteran’s primary care team and other VA providers, such as mental health. In some cases, this involved participating in care conferences with the Veteran’s primary care team. In one program, staff identified other VA supportive services that could help the Veteran and caregiver, such as home health aide services, adult day programs, or caregiver respite, then facilitated referrals with the primary care provider.

Although most programs’ primary efforts focused on improving communication and coordination within the VA, several programs worked to improve coordination with external, non-VA providers. At one site, several members of the dementia care team (a social worker, recreational therapist, and nursing assistant) made weekly visits to local adult day programs where Veterans received services. During these visits, team members implemented health maintenance activities (e.g., walking, getting up from a chair, etc.), caregiver support, nutritional counseling, and education for family caregivers and adult day program staff. At another site, a social worker collaborated with local contract home care agencies (i.e., non-VA agencies that provide services to VA patients) to streamline Veterans’ VA and non-VA care, such as when being discharged from the hospital. For example, the social worker would call the Veteran and caregiver to ensure planned follow-up appointments had been scheduled and find out if there were any transportation or other difficulties. In several programs, staff kept information about non-VA resources that may be available to help Veterans and caregivers, such as Medicare-covered services, programs offered through local organizations such as the Alzheimer’s Association, or other community-based services.

Common challenges

Respondents described several common challenges in implementing the programs. Numerous program leaders described staffing-related challenges, including difficulty hiring staff and staff turnover. These challenges were more pronounced in programs that were “brand new” versus expansions of existing services (such as dementia clinic expansions). Transportation was another common challenge, particularly for programs serving rural Veterans or those that conducted outreach to community clinics. At one site, program staff conducted outreach to VA community-based outreach clinics to identify Veterans who could benefit from specialized dementia services. However, once Veterans were identified, it was not always easy to arrange transportation to the medical center where dementia specialists were located. Finally, most programs reported challenges demonstrating program impact to medical center leaders. Although the VA has considerable clinical and administrative data available, accessing data requires specific knowledge and skills, and most programs did not have this expertise. Additionally, numerous respondents said important outcomes, such as quality of life, were difficult to measure. In the words of one leader: “we are improving outcomes but demonstrating cost savings and that ‘bad things’ were averted is difficult to do.” Another leader similarly commented: “[the program] is valued by administration and patients. It’s just not very measurable.” Challenges related to demonstrating measurable impacts to medical center leaders prevented the long-term sustainability of two dementia care programs.

Discussion

Through a retrospective review of program materials and data from interviews with personnel implementing 12 VA programs focused on helping Veterans with dementia remain in their homes and communities, we found several common strategies used across programs. Programs focused on supporting and involving family caregivers, strengthening interdisciplinary collaboration surrounding Veterans’ care, and improving communication and collaboration with other social service and healthcare providers. These findings expand on what is known about common models of dementia care by examining models implemented within the context of the VA, a large integrated healthcare system with different structures and resources from many other US healthcare systems.

Family caregivers play an essential role in supporting persons with dementia remain in their homes and communities, (Jutkowitz, Gaugler, Trivedi, Mitchell, & Gozalo, 2020) and we found that programs attempted to involve and support family caregivers through education, individual and group support, and individualized intervention and planning. The VA has recently expanded the education and other supports available to family caregivers. (U.S. Department of Veterans Affairs) Yet, even with support, the challenges faced by family members who care for a person with dementia can be considerable. Caregiver stress is one of the main predictors of institutionalization among persons with dementia, (Gaugler, Yu, Krichbaum, & Wyman, 2009; Toot, Swinson, Devine, Challis, & Orrell, 2017) as well as caregiver depression, reduced quality of life, and diminished physical health. (Berglund, Lytsy, & Westerling, 2015; Pinquart & Sörensen, 2011; Schulz, Boerner, Shear, Zhang, & Gitlin, 2006) Tailored interventions and support for caregivers (such as the strategies used by the programs we examined) can be effective at improving the quality of life of caregivers, as well as reducing depressive symptoms and burden. (Cheng et al., 2020; Toot et al., 2017) Although evidence about the effectiveness of caregiver support in delaying or preventing nursing home placement is less consistent, (Duan-Porter et al., 2020) studies have found that an intensive, multi-component intervention can be effective. (Gaugler, Reese, & Mittelman, 2013; Mittelman, Haley, Clay, & Roth, 2006) Innovative approaches to addressing caregiver needs, such as those implemented by the programs we examined, may provide a framework for other healthcare systems to engage and support family caregivers of persons with dementia.

Interdisciplinary team care has been an ideal of high-quality geriatrics for many years, particularly for older adults with complex care needs, such as those with dementia and other comorbidities. (Mion, Odegard, Resnick, & Segal-Galan, 2006) Over the past decade, the VA has focused on implementing the patient-centered medical home model, (Nelson et al., 2014) with specialized geriatrics teams used to provide care to some of the VA’s most complex older patients. (Sullivan, Eisenstein, Price, Solimeo, & Shay, 2018) Other US healthcare systems have similarly adopted the patient-centered medical home model of care, major goals of which include improving access to care, care coordination, and the comprehensiveness of care (i.e., care that addresses most of patients’ care needs, such as physical and mental health). (Jackson et al., 2013) In line with these goals, many of the dementia care models we examined sought to integrate medical and social services, such as by pairing a nurse and social worker to collaboratively manage the complexities of care coordination and other aspects of Veterans’ care. Several of the models also integrated mental health providers (psychologists and psychiatrists) and pharmacists to provide more comprehensive care to participating Veterans. Workforce shortages (e.g., of primary care physicians, mental health professionals, specialized geriatrics providers, and direct caregiving personnel, such as home health aides) increase the need to find new ways to provide comprehensive, coordinated care to individuals with dementia and other older adults with complex care needs. (Flaherty & Bartels, 2019) Several strategies include: 1) expanding the role of nurse practitioners, physician assistants, and clinical pharmacists to address patients’ primary care needs; 2) involving family caregivers as part of healthcare teams to improve communication, coordination, and support; 3) integrating geriatrics content more broadly into healthcare professional training programs so more healthcare providers are prepared to care for older adults with complex care needs; and 4) providing specialized geriatrics consultation services to primary care providers, such as through telehealth. (Bates et al., 2019; Flaherty & Bartels, 2019; Pimentel et al., 2019)

Healthcare systems are increasingly working to improve care for growing numbers of older adults, such as through the “age-friendly health system” (Fulmer, Mate, & Berman, 2018) framework (which the VA is similarly implementing). The VA has taken several other steps in recent years to improve dementia care. In 2019, the VA initiated the “Dementia System of Care,” a national effort focused on ensuring Veterans with dementia and their caregivers have access to comprehensive, coordinated, person-centered care. (U.S. Department of Veterans Affairs, Veterans Health Administration, 2019a) Over the past several years, VA has invested considerable resources in increasing Veterans’ access to home- and community-based services, such as skilled home care and home health aide services. (Thomas et al., 2018) Recent legislation has expanded Veterans’ access to care provided from non-VA providers but paid for by VA, which could particularly benefit rural Veterans and those with conditions like dementia that make traveling to a VA medical center more difficult. (Kelley, Greenstone, & Kirsh, 2020) These policy shifts within the VA have created opportunities to leverage the unique capabilities and expertise of VA and non-VA providers to provide the best care to persons with dementia. We described examples of how VA geriatrics specialists can support community providers (such as through the mobile adult day program), as well as how VA personnel can play an essential role in linking Veterans to non-VA supportive services available in their communities. At the same time, some of these changes also increase the need for better care coordination, particularly because growing numbers of Veterans are receiving care from both VA and non-VA providers. Ultimately, given the complex needs of persons living with dementia, ensuring high quality, person-centered dementia care requires flexible, multi-pronged approaches.

This review has several limitations. First, because VA sites developed programs based on their unique local needs, there was considerable variation across the programs we examined. At the same time, this heterogeneity enabled us to examine similarities and differences across programs with similar goals but serving different groups of Veterans in different local contexts. Thus, it is likely that the core strategies we observed (caregiver support, interprofessional collaboration, care coordination) would remain relevant in other contexts. Second, the programs were part of a single integrated healthcare system in the US, which could limit the generalizability of our findings. However, complex interventions typically require some adaptation in practice, including because no two older adults or families have the same needs, even when participating in the same program. Therefore, many of the strategies we describe could likely be adapted by other healthcare systems or providers based on their own needs and resources.

Our findings are based on interviews and self-reported information from dementia care program leaders. Future research could examine the perspectives of individuals living with dementia and family caregivers who participated in these and other dementia care programs to learn about their perspectives and experiences. Research is also needed to determine how best to adapt models of dementia care to different regional and cultural contexts. Insights gained from individuals with dementia and family members could be particularly useful in identifying gaps that could be addressed through future improvement efforts. Further, although most personnel described achieving positive results through the programs they implemented (such as reduced caregiver burden or avoidable hospitalizations), many also described challenges, which we have described. New, more accessible and adaptable ways of measuring program impacts are needed, particularly for complex patient populations. Cost savings may not be realistic – or the most important – goal. Further, some of the most important impacts may be “softer,” and more difficult to measure, such as improved communication or quality of life. Yet, particularly with complex chronic conditions such as dementia, these types of patient- and family-focused outcomes are equally or more important than clinical or cost outcomes and should be an integral part of assessing the impact of dementia care. Finally, programs take time to develop, and it may not be realistic to demonstrate cost savings or reduced adverse events (such as hospitalizations) in a two- or three-year period, particularly for smaller programs.

In conclusion, this study identified common strategies used by local VA programs to improve dementia care with the goal of supporting Veterans to remain at home and in their communities as long as possible. Although the programs implemented similar overarching strategies, the heterogeneity of specific approaches reflects the reality that the needs of persons living with dementia and family caregivers are vast. Regardless of setting, no “one size fits all” intervention can meet the care requirements of all person with dementia and family caregivers, highlighting the importance of innovative and flexible approaches to providing high quality dementia care. Ultimately, as the VA and other healthcare systems continue to adapt to meet the unique needs of growing numbers of persons with dementia, ongoing evaluation efforts will be essential in determining how to best leverage specialized dementia expertise while ensuring effective coordination of care for individuals with dementia and their families.