The intention of CATCH-ON Community Health is to bring together the key elements from evidence-based programs for managing multiple chronic conditions and ADRD among older adults in and around primary care. There are four components of the program: screening/risk stratification, assessment, care planning/ intervention, and self-management. Ideally, clinics would implement all elements of every level to best meet the needs of their older adult patients. Because clinics will have varying resources available (staff, time, space, electronic medical record accessibility), however, not every element will be possible initially but may build over time. Thus, CATCH-ON Community Health is a customizable program to meet the needs of each clinic with the resources available.
Every member of the clinic staff will be strongly encouraged to complete the CATCH-ON online modules that provide background for working in teams with older adults with multiple chronic conditions and their care partners. Staff will also be encouraged to join CATCH-ON Learning Communities, phone/video conference monthly meetings to discuss application of key elements of the online modules in each clinic.
The process of the CATCH-ON consultation mirrors our BRIGHTEN program in assessment, team recommendations, collaborative development of a clinic/community-centered implementation plan, and implementation support to enact the plan.
Readiness Assessment. The CATCH-ON consultation team will work with each partner clinic to assess the resources they have, their clinic priorities, and readiness for change. The first step of this assessment is for the clinic to complete a Readiness Assessment Instrument. The instrument includes online surveys for staff, leadership, and administration. The CATCH-ON consultation team with then have an in-person or video conference meeting with team leadership to follow up on results and clarify needs and resources.
Recommendations. The CATCH-ON team will then analyze survey responses and make recommendations about which elements to implement first, and over time. These recommendations will be discussed in meetings with clinic representatives to develop a collaborative implementation plan and timeline that all agree is desirable and doable.
Implementation support. Clinics will receive training from the CATCH-ON consultation team in elements of the plan that they are not familiar with. Connections to community agencies that are not already in place will also be made. The CATCH-ON consultation team will set periodic meetings (frequency determined by need) with clinic staff to address barriers to implementation, assure that the plan gets carried out as smoothly as possible, and engage in problem-solving to make changes to the plan as needed.
Outcomes. The CATCH-ON team, in collaboration with clinic staff, will measure clinic-level and patient-level outcomes of the new program. Some data will be collected from Medicare databases, some by clinic staff (time burden will be minimal), and some by the CATCH-ON Evaluation Team.
Resources for Partner Clinics
Managing Older Patients with Cognitive Impairment: A Guide for Primary Care Providers
Now What? Next Steps After a Diagnosis of Alzheimer’s Disease or Other Dementias
Assessing Cognitive Impairment in Older Patients: A Guide for Primary Care Physicians