Savvy Caregiver (Ostwald/Hepburn)


PRINCIPAL INVESTIGATOR:
Kenneth W. Hepburn, Ph.D.
Office of the Dean
Nell Hodgson Woodruff School of Nursing
Emory University
1520 Clifton Road, NE
Atlanta, GA 30322-4027
Room 318
Office: (404) 712-9286
Fax: (404) 727-6945 (fax)
Email: khepbur@emory.edu

OVERALL SNAPSHOT OF CAREGIVER INTERVENTION/PROGRAM:
The Savvy Caregiver Program is designed to train family and professional caregivers in the basic knowledge, skills, and attitudes needed to handle the challenges of caring for a family member with Alzheimer’s disease and to be an effective caregiver. This is a 12-hour training program/course that is usually delivered in 2-hour sessions over a 6-week period and can be adopted in other locations without direct involvement of the program initiators. Available materials for the program include a detailed trainer’s manual, a caregiver manual, a training videotape (DVD), and a CD-ROM. The program focuses on helping caregivers think about their situation objectively and providing them with the knowledge, skills, and attitudes they need to manage stress and carry out the caregiving role effectively. This packaged program allows a wide variety of organizations or groups to offer the program in their communities. Since 2002, it has been designated as one of the approved dementia training programs of the Alzheimer’s disease Demonstration Grants to States (ADDGS) program, which is funded through the U.S. Administration on Aging. The program has also been transformed into a self-contained version that can be delivered in many settings without direct involvement of the developers. This version was field tested with 140 family caregivers in rural Minnesota, Denver, and Anchorage, Alaska, with positive responses from the caregivers and the professionals who offered the training (health educators, nurses, social workers, recreation therapists, and geriatricians) (Hepburn et al., 2003).

Evidence demonstrating the program’s effectiveness in increasing caregiver skill, knowledge, and confidence as well as reducing caregiver distress has been shown (Hepburn et al., 2007; Hepburn et al., 2003). Research has demonstrated significant positive outcomes for caregivers who participated in the program versus those in the control group with respect to the caregivers’ beliefs about caregiving, their reactions to the behavioral symptoms of their care recipient, and their feelings of stress and burden (Ostwald et al., 1999; Hepburn et al., 2001).

BRIEF BACKGROUND RELATED TO THE DEVELOPMENT OF THE INTERVENTION:
The Savvy Caregiver program was developed in response to the absence of dissemination of successful programs from single randomized controlled trials (RCTs) into more general use within communities. Thus, the Savvy Caregiver Program was designed in an effort to demonstrate the translation of a successful psychoeducational program, originally developed and tested at the University of Minnesota, through a randomized controlled trial of its transportable version, the Savvy Caregiver program.

The Savvy Caregiver program originated from the Minnesota Family Workshop (MFW) which was aimed to improve outcomes for family caregivers and the persons with dementia through a multidimensional training approach provided to primary caregivers and other family members. The MFW used a general stress mediation model to conceptualize an approach to caregiver training. This model posits that multidimensional mediation may be needed to improve outcomes in a fundamentally stressful situation. According to the model, a number of factors that might mediate the impact of a caregiving situation have been suggested. These factors include the caregiver’s personal resources for caregiving (knowledge, skills, and belief in own abilities) and external resources for caregiving) (Ostwald et al., 1999; 2003). Keeping in line with this theoretical framework, Ostwald and colleagues developed a 14-hour training workshop (provided in seven weekly, 2-hour training sessions) for primary caregivers and their families. The caregiver workshop consisted of a multifaceted curriculum that emphasized the development of individualized strategies of care designed to: provide information about dementing diseases and how they affect persons with dementia, caregivers, and the family system, strengthen caregivers’ practical skills for dealing with daily caregiving tasks, increase caregiver confidence, and improve communication and cooperation by increasing the congruence of caregivers’ and families’ perceptions about the nature and level of impairment of a person with dementia. The sessions were designed and conducted by university faculty with disciplinary backgrounds in nursing, family therapy, education, and occupational therapy. The program’s curriculum was designed to train caregivers to work in the unfamiliar role of caregiving. Thus, the curriculum was designed to help caregivers objectively appraise their situation while providing them with the knowledge, skills, and attitudes needed to handle stress and carry out the role of caregiving.

The MFW workshop followed a written curriculum that identified teaching points and learning objectives for each session. The curriculum specified the faculty, exercises, readings, and homework for each session, and the workshop maintained a classroom format. During the development, one of the intervention investigators monitored each session to ensure that the teaching points were adhered to as planned. In a randomized controlled trial, the intervention was effective in reducing caregiver burden, depression, and reaction to behavior and in helping caregivers achieve a less emotionally enmeshed attitude (Hepburn et al., 2001; Ostwald et al., 1999).

The investigators recognized that in creating the MFW that for large numbers of family caregivers to benefit from successful research-based training programs, the programs must be translatable to other locations for widespread dissemination. This led to the development and testing of a “practice-translation” project, the Savvy Caregiver Program (SCP) which was modeled after the MFW. Savvy caregiver was designed to offer organizations a means of implementing an evidence-based caregiver psychoeducational program without the direct involvement of the program initiators. Hepburn and colleagues (2003) worked with the Alzheimer’s Association of Minnesota and developed a prototype of the Savvy Caregiver Program, designed to overcome the challenges of transportability. The prototype was a 12-hour, self-contained dementia caregiver training program that could be offered in the community by a variety of providers.

Implementation of Savvy Caregiver through Colorado ADDGS Grant
Since 2002, Savvy Caregiver training has been provided by a consortium of agencies in Colorado with funding from the Administration on Aging through the Alzheimer’s Disease Demonstration Grants to States (ADDGS) program. A major objective of the Colorado project was to reach rural caregivers. The consortium believed that Savvy Caregiver training would be particularly useful for these caregivers because it teaches caregivers to use a comprehensive manual and CD-ROM that can help them with future caregiving problems even if they do not have access to services in their local communities. Since many rural caregivers would have difficulty traveling long distances for 2-hour training sessions over a 6-week period, the Colorado consortium provided Savvy Caregiver training in longer sessions that were delivered in one day, or one day a week for two weeks or three weeks.

Research from the Colorado ADDGS project indicates that Savvy Caregiver training is effective in reducing depression and increasing the use of support groups by rural caregivers. The 1- 2- and 3-day training formats appear to be equally effective and make the program available to rural caregivers who would not be able to receive the training if it were delivered in shorter sessions over a 6-week period. The ADDGS project in Colorado has published two journal articles in support of that research. One article entitled, “Examining the Effectiveness of the Savvy Caregiver Program among Rural Colorado Residents” is available online. The second article entitled, “Number of Training Sessions Does Not Change Program Effectiveness: Evaluation of Formats of One, Two, or Three Sessions For the Alzheimer’s Savvy Caregiver Training Program” is available for a charge on Sage Publications website. Additionally, the ADDGS National Resource Center completed a case study on Colorado's ADDGS program.

TARGETED CAREGIVER POPULATION (AGE, ETHNICITY, CONDITION/DISEASE):

The primary targeted caregiver population studied has been for adult caregivers of persons with Alzheimer’s disease. The program has been tested predominantly among Caucasian caregivers in clinical trials.

MANUAL OF PROCEDURES: The Savvy Caregiver Program Manual is included with the purchase of the DVD and CD-ROM. See section below titled Video clip of Caregiver Intervention/Program. To view an excerpt of the manual, please visit the following website: http://www.hcinteractive.com/images/SavvyCaregiverManualExcerpt.pdf
Also, to view an introduction to the trainer manual, please visit the following website:
http://www.raisingbar.eventwebsitebuilder.com/f/Savvy_Caregiver.pdf
Stand-alone manuals serve as curriculum guides, provide a course description complete with learning objectives, map out the learning activities of each of the six 2-hour sessions, and constitute the “text” for the course. The manual orients the caregiver to the program and provides specific learning objectives. The manual specifies the order of talks and exercise in each of six 2 hour sessions as well as provides slides and handouts and homework. The 6 sections of the manual include: 1) introduction to dementing disorder; 2) caregiver self-care; 3) the anchors of enjoyable involvement; 4) levels of thinking and performance; 5) strengthening the family as a resource for caregiving; and 6) review and integration of the previous sections. The manual is complemented by an available CD-ROM “Alzheimer’s Caregiving Strategies” (Healthcare Interactive, 2001), or by a videotape produced by the authors. There is a trainer’s manual as well as a caregiver’s manual.

OUTCOME MEASURES: Various outcome measures have been used to evaluate the efficacy of the intervention in randomized controlled trials (RCTs). These evidence-based outcome measures are briefly described below along with their main reference if you are interested in reading more about the measure or obtaining it. Recently, Scharf and colleagues (2006) developed program evaluation specific measures consisting of several questions from which to evaluate the overall program as well as the effectiveness of the program. This may be used as an intervention targeted outcome measure designed specifically for this program and is also described briefly in the following section. More studies are needed to evaluate the psychometric properties of the questions/measures. However, this may provide supplemental information when determining program satisfaction.

Outcome Measures Related to the Patient with Dementia (Care-recipient)
Frequency of Occurrence of Behavioral Problems. The Revised Memory and Behavior Problems Checklist (MBPC; Teri et al., 1992), a has been used to measure caregiver rating of the extent and severity of care recipient behaviors in four domains (memory, behavior, paranoia, and depression); it also includes a caregiver self-assessment of the extent to which she or he is bothered y each of these behaviors (e.g., caregiver reaction).

Main Reference for this Measure: Teri, L., Truax, P., Logsdon, R., Uomoto, J., Zarit, S., & Vitaliano, P. O. (1992). Assessment of behavioral problems in dementia: The revised memory and behavior problems checklist. Psychology and Aging, 7, 622-631.
.
Outcomes Measures Related to Caregiver Well-Being
Burden. The Caregiver Burden Scale (Zarit et al., 1985), a 22-item self-report measure, has been used to evaluate the level of burden or distress associated with caregiving.

Main Reference for this Measure: Zarit, S., Orr, N., Zarit, J. (1985). The hidden victims of Alzheimer’s disease: Families under stress. New York: New York University Press.

Depressive Symptomatology. The Center for Epidemiological Studies-Depression Scale (CES-D: Radloff, 1977), a 20-item self-report measure, has been used to measure depressive symptomatology.

Main Reference for this Measure: Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401.

Caregiver competence. A Mastery scale (Pearlin et al., 1990) has been used to evaluate the impact of this intervention on self-assessment of caregiving competence.

Main Reference for this Measure: Pearlin, L. I., Mullan, J. T., Semple, S. J., & Skaff, M. M. (1990). Caregiving and the stress process: An overview of concepts and their measures. The Gerontologist, 30, 583-594.

Emotional enmeshment. The Beliefs About Caregiving Scale (Phillips et al., 1989) has been used to assess the emotional enmeshment of the caregiver.

Main Reference for this Measure: Phillips, L. R., Rempusheski, V. F., & Morrison, E. (1989). Developing and testing the Beliefs About Caregiving Scale. Research in Nursing and Health, 12, 207-220.

Intervention-Specific Measures
Satisfaction with program. A Savvy Caregiver (SCP) overall program evaluation measure has been used to evaluate how many sessions training consisted of as well as overall satisfaction with the program (Scharf et al., 2006). Questions include, “I feel the content of the Savvy Caregiver workshop was relevant to my situation”, “I feel I learned some useful strategies for caregiving”, and “As a result of taking part in the SCP, I feel more confident in myself as a dementia caregiver”, with a 5-point response scale.

Effectiveness of program. Questions pertaining to the effectiveness of the training and the use of the materials were developed (e.g., “Since completing SCP I have used the manual for reference”, “Using the manual helped me to structure meaningful household activities for the person with dementia”) using a 5-point response format.

WORKBOOK/WORKSHEETS: A Savvy Online Workbook is in the works. In the Savvy Online Workbook, caregivers will be able to put their new knowledge to use with this innovative Internet-based resource. Specifically, they will learn the difference between common responses to situations and a "Savvy Approach" at early, middle, and late stages of memory loss; view expert and family member video responses to many of caregivers most asked questions about memory loss; and do interactive practice exercises to reinforce what caregivers learned about being a savvy caregiver. Please see the section of this program write-up titled “COST AND TIME CONSIDERATIONS” for contact information and availability.

OTHER INTERVENTION RESOURCES: A CD-ROM is available which parallels that of the original MFW and SCP. Using video clips of persons with dementia who are being tested in the performance of an everyday task (e.g., making toast), the CD-ROM introduces caregivers to the performance staging system and encourages them to estimate where their care recipient falls along with the performance stages.

LENGTH OF INTERVENTION/PROGRAM:
Six 2-hour sessions each for a total of 12 hours across a 6 week period

NUMBER OF SESSIONS: 6

LENGTH OF EACH SESSION: 2-hours per session

DESCRIPTION OF SESSION CONTENT:

The Savvy Caregiver Program follows a curriculum that identifies teaching points and learning objectives for each session. The curriculum describes the exercises, readings, and homework for each session, and the workshop maintains a classroom format.

Overview of the Intervention Curriculum Objectives:
Acknowledge the disease: This objective entails understanding and coming to grips with the disease that is impacting the person and recognizing it is not personal. Rather it is the disease and not the person that is causing difficulties.

Make the cognitive shift: This objective involves developing a strategic sense of what cognitive losses are occurring and how caregiver behavior has to adapt to these as they take place and progress in the program.

Develop emotional tolerance: This involves recognizing the central role of confusion in dementia and becoming aware of how it contributes to troubling behaviors (e.g., shadowing or repetitive questioning). This also entails an appreciation of the care recipient’s need for emotional stability in the face of confusion.

Take control: This objective involves understanding that dementia gradually erodes autonomy and appreciating social and emotional difficulties involved in taking control of another adult. This also involves learning how to recognize the need to take control and be willing to do this.

Establish a realistic care goal: Caregivers learn to accept developing realistic goals for caregiving by recognizing rehabilitation and progression of the disease process as it progresses.

Gauge the care recipient’s capabilities: For this objective, caregivers learn how to estimate the care recipient’s capacity for involvement in tasks and activities using an occupational-therapy based staging system.

Design opportunities for satisfying occupation: Caregivers learn to design tasks or activities in which the person can become engaged and will take pleasure in. Additionally, the caregiver learns to communicate effectively with the care-recipient to promote and maintain involvement.

Become a sleuth: Lastly, caregivers learn to utilize a problem-solving approach to caregiving, one that involves being able to stand back from the situation (emotionally), identify the problem, create hypotheses about causes of behavior, generate solutions, make decisions, and verify that the solution implemented effectively solved the problem.

METHOD OF ADMINISTRATION/DELIVERY:
This program is fully transportable and delivered via a videotape (DVD), CD-ROM, and manual with objectives. This can be administered as an individual or group based program.

TRAINING:
This is a stand-alone program. The manual serves as a curriculum guide, provides a course description complete with learning objectives, maps out the learning activities of each of the six 2-hour sessions, and constitute the “text” for the course. The manuals are complemented by an available CD-ROM, “Alzheimer’s Caregiving Strategies” (Healthcare Interactive, 2001), or by a videotape produced by the PI and program developers. This packaged caregiver program allows a wide variety of organizations, groups, or community agencies to offer the program.

According to Hepburn and colleagues (2007), program leadership is typically provided by persons with an educational or clinical background or who have experience with family caregivers of older adults with Alzheimer’s disease and other dementias. A leader/trainer assists with facilitating within the parameters of the training program. Referrals to address other needs (e.g., information/support) are made on an as needed basis versus transforming the program into a counseling program. Hepburn et al. (2003) also advise that leaders are familiar with both caregiver and leader manuals to help with the flow of different aspects of the program (e.g., exercises, homework).

COST AND TIME CONSIDERATIONS:

Leader/trainer to facilitate within the parameters of the training program
Access to a computer and/or DVD player
DVD and Homework Materials:
Savvy Caregiver DVD: Consists of 4 DVDs and is designed to be watched once a week for four weeks. Estimated cost for this is listed as $49.95.

Homework CD-ROM: In each of the 4 DVD sessions, the instructor asks the caregiver to complete a homework assignment on the Homework CD-ROM. This program runs on a PC or Mac computer, and is approximately 2 hours in length. It is not required that the caregiver completes the CD-ROM as part of the Savvy Caregiver educational program, but it is recommended. Estimated cost for this is listed as $29.95.

Coming soon, is the Savvy Online Workbook: After watching the Savvy Caregiver 4-DVD set, many customers asked if there's anything else that might help them extend their knowledge—so the developers are creating the Savvy Online Workbook. With the DVD set, caregivers can watch and learn about becoming a savvy caregiver. In the Savvy Online Workbook, they will be able to put their new knowledge to use with this innovative Internet-based resource. Specifically, they will learn the difference between common responses to situations and a "Savvy Approach" at early, middle, and late stages of memory loss; view expert and family member video responses to many of caregivers most asked questions about memory loss; and do interactive practice exercises to reinforce what caregivers learned about being a savvy caregiver.

Caregiver DVD or the Homework CD-ROM, please contact HealthCare Interactive.

VIDEO CLIP OF INTERVENTION/PROGRAM:
The Savvy Caregiver is offered in a classroom format in over ten states around the country, but was converted to a DVD format in 2007 as a way of making the information accessible to people across the entire country. The Savvy Caregiver DVD was filmed in Denver, Colorado in 2006. The DVD was completed in 2007 and was released for sale to the public in January of 2008. The Savvy Caregiver Program Manual is also included with the purchase of the DVD.

DOWNLOADABLE FACT SHEET:
Savvy Caregiver Talking Points

ADDITIONAL INFORMATION:
Alzheimer's Disease Supportive Services Program

BRIEF DESCRIPTION OF EVIDENCE:
Evidence supporting the efficacy of the Savvy Caregiver program has been well documented. Hepburn et al. (2003) found that the program was successful in making caregivers feel more knowledgable, more confident, and more skilled as caregivers. In another study, Hepburn and colleagues (2007) also found that in a total of 52 caregivers, caregivers in the experimental group (intervention group) had significantly better scores on measures of mastery and distress compared to caregivers scores in the control (no intervention) group at post-intervention. Smith and Bell (2005) evaluated the program in 54 rural and 42 urban caregivers who participated in the Savvy Caregiver program in their local communities, with training of 1 week, 2 week, or 3 week sessions by staff of the Alzheimer’s Association, Colorado chapter. Results indicated positive outcomes of the training were found at 6-month follow-up for both the rural and urban groups. Caregivers reported structuring meaningful activities for the person with dementia. Additionally, lowered scores for depression were found for the rural group, and overall support use was increased.

Modification of the format does not appear to sacrifice desired outcomes. For example, Scharf and colleagues (2006) found that altering the number of training session did not change program effectiveness in rural caregivers. In other words, one large dose as opposed to multiple small doses (e.g., usual six sessions) which may be more realistic for hard to reach caregivers in need of training.

REPRESENTATIVE PUBLICATIONS/REFERENCES:

Hepburn, K., Lewis, M., Tornatore, J., Sherman, C. W., & Bremer, K. L. (2007). The Savvy Caregiver Program: The demonstrated effectiveness of a transportable dementia caregiver psychoeducation program. Journal of Gerontological Nursing, 30-36.

Hepburn, K. W., Lewis, M., Sherman, C. W., & Tornatore, J. (2003). The Savvy Caregiver Program: Developing and testing a transportable dementia family caregiver training program. Gerontologist, 43(6), 908-915.

Hepburn, K. W, Tornatore, J., Center, B., & Ostwald, S.W. (2001). Dementia family caregiver training: Affecting beliefs about caregiving and caregiver outcomes. Journal of the American Geriatrics Society, 49(4), 450-457.

Ostwald, S. K., Hepburn, K. W., & Burns, T. (2003). Training family caregivers of patients with dementia: A structured workshop approach. Journal of Gerontological Nursing, 29(1), 37-44.

Ostwald, S. K., Hepburn, K. W., Caron, W., Burns, T., & Mantell, R. (1999). Reducing caregiver burden: A randomized psychoeducational intervention for caregivers of persons with dementia. Gerontologist, 39(3), 299-309.

Scharf, L., Bell, P. A., & Smith, S. A. (2006). Number of training sessions does not change program effectiveness: Evaluation of formats of one, two, or three sessions for the Alzheimer’s Savvy Caregiver Training Program. Dementia: The International Journal of Social Research and Practice, 5, 559-569.

Smith, S. A., & Bell, P. A. (2005). Examining the effectiveness of the Savvy Caregiver Program among rural Colorado residents. Rural and Remote Health 5 (online), 2005: 466. Available from: http://rrh.deakin.edu.au/articles/subviewnew.asp?ArticleID=466