Dementia Care Quality at Home: A Dementia Care Curriculum for Home-Based Primary Care

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Sheehan, Maimouna Sy, Christine S. Ritchie, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8001358/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Dementia is highly prevalent among the 7.5 million homebound older adults in the United States. Despite this high dementia prevalence, dementia care interventions and associated curricula developed to date have focused nearly exclusively on office-based primary care and have not been adapted to the unique care setting, staffing, and workflows of home-based primary care (HBPC). We developed and implemented a pilot study of the Dementia Care Quality at Home (DCQH) curriculum to train HBPC clinicians and staff in person-centered dementia care. The objective of this study is to evaluate the DCQH curriculum. Method The curriculum comprised 8 required and 4 optional asynchronous video modules, two 90-minute synchronous skill-building sessions focused on training for implementation of a standardized assessment, and six core dementia care modules through structured home visits, and monthly case conferences. Learners completed baseline assessments and care modules with patients and caregivers, followed by fidelity reviews and post-intervention focus groups. We assessed learners’ knowledge via training questionnaires, completion rates, fidelity of assessments and modules, and the reported feasibility and acceptability of the curriculum using both quantitative and qualitative methodology. Results Twenty-one HBPC clinician and staff learners completed training and post-curriculum surveys. Fifty assessments and 256 dementia care modules were successfully delivered, with 92% fidelity by audit. Learners qualitatively reported increased confidence in dementia care domains including symptom management, behavior strategies, caregiver support, and interdisciplinary collaboration. Focus groups highlighted improved team cohesion and consistent care delivery. Caregivers valued having structured time outside of traditional medical visits to address dementia-specific concerns. Conclusion The DCQH curriculum improved knowledge, workflow integration, and interdisciplinary collaboration among HBPC teams, while offering caregivers enhanced support. This structured, scalable model shows promise for improving dementia care delivery in home-based settings and may serve as a framework for future training in geriatric care settings. Background Approximately 7.5 million older adults in the United States are homebound.(1) Between 40-80% of homebound older adults have dementia, which imposes a significant burden not only on patients but also on their caregivers, who frequently experience high levels of stress, anxiety, and reduced emotional well-being.(2) Homebound older adults’ access to ambulatory office-based primary care is often limited. Home-based primary care (HBPC) provides comprehensive, longitudinal medical care delivered by an interdisciplinary team including physicians, nurse practitioners, nurses, social workers and others directly in patients’ homes. It is designed for individuals who are homebound. Given that the prevalence of dementia among homebound older adults is approximately 50%, HBPC practices must be equipped to provide high-quality dementia care that supports both patients and caregivers. Existing dementia care models, such as Care Ecosystem and its adapted version, CRESCENT, were developed for and have demonstrated benefit in office-based primary care by implementing standardized assessments, evidence-based interventions, and team-based case conferencing.(3,4) These models have improved patient quality of life, reduced caregiver burden, and enhanced clinician competency in dementia care. HBPC differs significantly from office-based care, and existing models require significant adaptation to be effective in HBPC where the prevalence of dementia is much higher and the clinical workflows and practice resources vary significantly compared to office-based practice. To bridge this gap, we developed and tested the feasibility and acceptability of the Dementia Care Quality at Home (DCQH) care model to deliver comprehensive, person-centered dementia care by HBPC practices.(5) As part of DCQH, we developed a structured curriculum to train HBPC clinicians and staff in delivering dementia care. The goal of this paper is to describe the development and evaluation of the DCQH curriculum. This curriculum was intended to optimize dementia care for homebound older adults receiving HBPC by improving the knowledge, skills, and collaborative methods among providers and staff in HBPC practices and to support the caregivers of people living with dementia (PLWD). Methods Overview Learners The targeted learners for the curriculum were HBPC clinicians (physicians, nurse practitioners, nurses, social workers) and staff (receptionists, schedulers, XXX) in two HBPC practices in which the DCQH was pilot tested for feasibility and acceptability. Each practice designated personnel to participate in the pilot study and engage with the curriculum. Learners were expected to have prior experience of caring for PLWD and their care partners through their experience in HBPC. The curriculum employed a standardized approach across HBPC practices. Learning Goals The learning goals of this curriculum were designed using Bloom’s Taxonomy to promote progressive skill development from foundational knowledge to applied clinical practice.(6) Learning goals were conceived at the individual learner level and at the practice level. After completion of the curriculum, individual learners were expected to be able to: 1) describe key aspects of dementia and dementia care 2) conduct standardized assessments and prioritize relevant care challenges to be addressed, and 3) deliver care using structured dementia care modules to caregivers of PLWD. By the end of this curriculum, HBPC practices were expected to be able to 1) implement a standardized strategy for dementia care management appropriate to the workflows of the HBPC practice and 2) support caregivers of people living with dementia through a structured care model. Curriculum Components and Training There were two major components of the curriculum 1. Asynchronous training The asynchronous training comprised 12 video modules (8 required and 4 optional) (Appendix 1) on key issues in dementia and dementia care adapted to home-based care to be completed at a time convenient for each learner. The total time across all required and optional modules was 2 hours and 38 minutes and average video module length was 13 minutes long. Table 1 depicts modules topics and associated learning goals. Synchronous training DCQH adapted the Care Ecosystem dementia care model and its clinician-oriented adaptation, CRESCENT for the HBPC setting.(7) Using the FRAME adaptation framework, the program was designed through stakeholder engagement to ensure relevance, usability, and integration into HBPC workflows.(8,9) DCQH retained three core components from Care Ecosystem: A structured baseline needs assessment for PLWD and their caregivers. Six dementia care modules, prioritized based on needs assessment findings: medication management, safety, behavior management, decision-making, caregiver well-being, and community resources. Each module provided specific structured guidance on a) assessment, b) management strategies, c) caregiver-focused resources, adapted for the HBPC setting. A biweekly, team-based case conference for discussing patient needs and intervention-related learnings. The synchronous training comprised two 90-minute live sessions over Zoom video conference with trainers and the entire practice clinical and non-clinical staff that would be involved in delivering DCQH care. The first live synchronous training session, “Skill Building and Support Session 1,” with a PowerPoint presentation (Appendix 2), included in-depth information about the role of a learner, the needs assessment, the structure and components of a module, and a simulation of how to prioritize modules for implementation with a patient based on data obtained from the needs assessment. The second live synchronous training session “Skill Building and Support- Session 2” with a PowerPoint presentation (Appendix 3) provided in-depth reviews of each DCQH care module with details on implementation including a step-by-step simulation of conducting a module with a caregiver and patient in the home. Implementation in Clinical Practice HBPC practices designated at least one dementia-trained clinician to lead DCQH integration into the practice. Training for all participating clinicians and staff included asynchronous training, live synchronous modules, and ongoing support. HBPC staff trained in DCQH conducted the baseline needs assessment in the home. Direct observation of the home environment and caregiver-PLWD interactions supplemented the assessment. Following completion of the needs assessment, HBPC clinicians engaged caregivers in a prioritization discussion to determine the order in which to implement modules with the caregiver over time. Learners (trained HBPC staff) delivered care modules to caregivers and patients in the home setting based on their clinical workflow of home visits over the subsequent months. Measures At the end of each asynchronous module, all learners completed a learning assessment (Appendix 4). This assessment included a mix of Likert scale, multiple choice, and open response questions: “on a scale of 1-10, how much did this session help you?”, “Tell us about the level of detail (not enough, just enough, or too much) and “How much time did it take you to complete this training” (not enough, just enough, or too much). Open responses included “Were there any other topics that you would have liked for us to cover during this module” and “What was your biggest takeaway/learning from this presentation?” The research team quantitatively analyzed the Likert scale and multiple-choice answers and qualitatively coded open responses to generate key takeaways. The Likert scale scores (1-10) and key learnings are present in Table 1. The research team conducted follow-up surveys for learners after the completion of the intervention implementation in clinical practice. To assess the learners' ability to conduct and complete standardized assessments and prioritize relevant challenges, the team documented the number of assessments conducted and assessed the fidelity of learners in conducting the standardized learning assessments with caregivers in the home setting. Five de-identified baseline needs assessments and one of each of the 6 care modules were randomly selected from each site for fidelity evaluation. The assessments and care modules were reviewed by study team members (MS, AT). Fidelity was rated as complete if all elements of the baseline needs assessment and the modules were completed or partially completed (some but not all elements were completed). To assess the learners’ ability to deliver structured care modules to caregivers of people living with dementia, we documented the number of total modules conducted by each practice and assessed the fidelity of learners delivering care modules with caregivers in the home setting. To measure the fidelity of assessments and modules, we obtained a random sample of 10 completed assessments and 12 completed modules from practice sites. In addition to the follow-up survey, HBPC practice staff participated in a focus group (one 1-hour focus group per site) to share qualitative data on their experience during the training and implementation of the DCQH intervention (Appendix 5). The focus groups were analyzed using deductive live rapid data analysis during focus groups.(10) Results Learners-level results: 21 learners (3 MDs, 10 NPs, 3 RNs, 3 SWs, 2 administrative staff members) from two HBPC practices completed training and the post-curriculum follow-up survey. Participants' scores regarding how much the module helped them, separated by training module, and a qualitative response summary, are depicted in Table 1. On average, scores for the required modules were 9.21/10 and 7.42/10 for the optional modules. After module completion, learners highlighted a stronger understanding of dementia pathophysiology, dementia subtypes, medication management, caregiver needs, safety planning, behavior strategies, and decision-making capacity and finances. Learners also stated that the optional modules reinforced the importance of early planning for guardianship, avoiding unnecessary hospitalizations, prioritizing comfort in advanced dementia, and connecting veterans to underused benefits. Nineteen learners self-reported a total of 50 completed assessments and prioritization of module order (100% completion rate). However, only 70% of audited baseline assessments were fully completed. Thirteen learners delivered a total of 256 modules, and 92% of audited modules were fully completed. Practice-level results: During the post-intervention focus groups, practices reported that the DCQH training and case conferences effectively standardized dementia care knowledge across interdisciplinary team members. “It’s truly an [interdisciplinary] team, and everybody’s really focused on: How do we become more efficient, and how do we serve our patients better, and how do we do our job better, as well as, hopefully, do our job more efficiently, so it doesn’t leak out into our personal lives? (ID 1) “I definitely think how we structured it really helped, too, that we really took it as like a whole team approach, um, and that it wasn’t just like one or two people doing the modules for all the patients? That we really were mindful about splitting everything as evenly as possible, and, um, you know, having people from different disciplines participate” (ID 4) “I think it’s good to have it standardized that everybody on your team go through them, so we’re all working with the same background” (ID 5) "I do feel like the meetings with the other practice were helpful. Like, I learned some pearls and tips and tricks from the team, from the team." This uniformity in training fostered a shared language and understanding of dementia care practices, promoting a more cohesive and collaborative approach to patient management. Providers noted that this alignment improved team communication and contributed to more consistent and coordinated care delivery. Caregivers of people living with dementia expressed appreciation for having dedicated time outside of routine medical appointments to focus on dementia-specific concerns. “Making the time and making it personal... as far as, not only did we care for our population, but also, that we’re taking interest in them, and just going, above and beyond in a sense” (ID 7) “I got the sense that it made them feel like we were doing something special for them...“We’d like you to participate in this special thing..." And I got the sense, they were very appreciative.” (ID 9) "You know, the-the materials that you gave us, the fact that we could pick and choose and customize a little bit for the patient based on what we discussed in the, um, checklist, uh, that-that was helpful." (ID 4) Learners found the structured case conferences helpful for addressing questions, learning tips from other practices on managing dementia related issues in the home, and understanding each other's workflows and bandwidth to address assessment and module completion. Table 1: Learning Goals, Scores, and Key Takeaways for each Asynchronous Training Module Training Module Learning Goals Help score [1-10]* Average, SD Summary of Key Takeaways REQUIRED (n=21) Dementia Basics Part 1 Describe the functional characteristics of different parts of the brain and how they relate to symptoms of dementia Describe the main theory for what causes dementia Describe why new biomarker tests are being developed to improve diagnosis of dementia 8.57, 1.67 Learners appreciated the clear review of dementia pathophysiology, stages, and brain structure, especially with visuals linking brain regions to specific symptoms and disease variants. The training reinforced that different types of dementia have distinct causes, behaviors, and symptoms, and highlighted the modest role of available treatments in slowing cognitive decline without curing the disease. Dementia Basics Part 2 Describe symptoms that characterize vascular dementia Recognize modifiable risk factors for vascular dementia Review common medications used for people with vascular dementia 9.29, 1.27 Learners appreciated the clear distinctions between dementia subtypes and the importance of subtype-specific management. Learners valued reminders about modifiable risk factors and how different dementias affect symptoms and caregiving needs. Medications Describe an adverse drug reaction Provide a brief overview of selected guidelines related to geriatric therapy (Beers List, START and STOPP criteria) Identify medications used for common problems in dementia Understand the expected benefit of medications for dementia, Describe dosing and monitoring for cholinesterase inhibitors and memantine 8.95, 1.31 “The new approved medications for dementia have a very modest benefit.” Learners understood that there are different medications for different types of dementia and adverse effects of certain medications. Caregiver Wellbeing Understand the negative and positive impact that dementia can have on the family caregiver in terms of their physical health, mood, financial wellbeing Identify at least two reasons why a caregiver might enjoy or find meaning in being a caregiver 9.10, 1.38 Learners appreciated the emphasis on treating caregivers as integral members of the care team, highlighting both the challenges and the positive aspects of caregiving and the need for proactive support and care planning. There was strong recognition of the importance of monitoring caregiver well-being, providing resources, and using dementia-trained clinicians to identify and address caregiver needs systematically. Safety Recognize five key and common home safety risks associated with dementia Identify four strategies for reducing safety risks for persons with dementia 9.28, 1.27 Caregivers and providers must move beyond "hope" by proactively assessing and planning for home safety risks to prevent emergencies and support safer aging in place. Simple yet critical interventions—like securing furniture, removing locks, using safety checklists, and educating caregivers—can significantly reduce fall risks and accidents for people living with dementia. Behavior Management Understand that behavior symptoms correlate with areas of brain damage Recognize five unmet needs that may contribute to behavior symptoms Identify five potential environmental triggers for behavior symptoms Identify three caregiver factors that contribute to behavior symptoms 9.14, 1.35 Behavioral symptoms in dementia are often influenced by environmental factors, caregiver responses, and unmet needs, and can frequently be managed effectively through non-pharmacologic strategies like the DICE approach before turning to medications.(11) Understanding the differences between dementia and delirium, and emphasizing systematic, empathetic communication is crucial for better caregiver support and patient outcomes. Decision Making Upon completion of this training module, you will be able to: Apply ethical/legal standards of capacity to your work Explain how to assess for capacity and who can make determinations of capacity, and on what grounds 9.28, 1.27 Learners emphasized that advance care planning is a continuous process, not a one-time document, and should begin early while patients still have decision-making capacity. There was appreciation for clarifying that capacity is task-specific (not global), fluctuates over time, and differs from legal competence, with guidance on assessing capacity and identifying appropriate surrogates. Financial Describe the qualities of a good financial caregiver Understand why it is important for a person with dementia to have legally-recognized financial caregivers. 9.05, 1.43 Learners emphasized the critical need for early financial planning, encouraging patients to appoint a trusted financial power of attorney (POA) while they still have capacity to prevent future legal and financial hardships. There was an appreciation for learning about the differences between financial and healthcare planning, various account options, and the legal distinctions between capacity and competency. OPTIONAL Guardianship* Define guardianship Name at least two ways to help avoid guardianship 7.17, 1.83 n=6 Appointing guardianship earlier is better to avoid complications later in the disease process: “the earlier the better”. Guardianship can be expensive and is not the best option if it can be avoided. Hospitalizations* Describe why people with dementia are at increased risk of hospitalization Identify common risks and reasons for hospital admission among persons with dementia receiving home-based primary care Describe adverse outcomes of hospitalization for people with dementia Describe strategies for reducing unnecessary hospitalization among people with dementia receiving HBPC 7.50, 2.07 n=5 Recognizing the warning signs of delirium, providing caregiver education, and using claims-based data and flow charts are important strategies for managing dementia care. Tube Feeding* Understand most patients' progression from mild to moderate to advanced dementia Explain why tube feeding is not recommended for patients with difficulty eating Explain why we try to avoid hospitalization in advanced dementia 7.17, 2.32 n=6 Learners understand that tube feeding in advanced dementia does not improve mortality outcomes. In advanced dementia care, prioritizing comfort over calorie count reflects a more compassionate, lifestyle-centered approach. VA Benefits* Learn the different types of benefits available to veterans, including income benefits Understand the basics of VA healthcare Know where to send veteran patients and families to get help with VA benefits 7.83, 1.94 n=6 Learners gained awareness that there are many underused benefits, such as home health aides and respite options, and service providers may need to guide caregivers to access these resources. Discussion This study demonstrates that a structured dementia care curriculum adapted for the HBPC setting can be implemented and can improve the knowledge, skills, and collaborative practices of interdisciplinary teams while enhancing support for caregivers of PLWD. The DCQH curriculum was well-received by both groups of learners, supporting its utility as a scalable model for dementia care education in non-traditional care settings. Consistent with prior work on the Care Ecosystem and CRESCENT models, learners reported that standardized training and case conferencing helped create a shared language and collaborative approach to dementia care delivery.(3,4) This finding reinforces the importance of team-based education in dementia care, especially in HBPC settings where team members often operate autonomously. By creating consistency across providers, the curriculum supported more integrated and efficient care delivery, a known facilitator of quality outcomes in home-based care.(12) Participants also valued the flexibility and adaptability of the care modules, which allowed providers to tailor interventions to individual caregiver needs—a key principle of person-centered dementia care.(13) Challenges to training implementation were primarily logistical, including scheduling barriers and a desire for more concise training materials. These challenges mirror findings from similar educational interventions in geriatric and dementia care, which often cite time constraints and workflow disruption as barriers to adoption.(14) Streamlining modules and building in flexibility for delivery may further enhance uptake and sustainability across diverse practice settings. Strengths of this study include its focus on a previously underexplored setting, home-based primary care (HBPC), and its implementation across two diverse, health-care delivery sites, one in Virginia, and one in Hawaii, allowing for insights into curriculum adaptability across varying contexts, health systems and populations. Additionally, the curriculum was open to all staff in the home-based primary care practice, both clinicians and non-clinicians, ensuring a consistent and comprehensive framework to assess outcomes on an individual learner and practice level. Limitations include the use of self-reported data, which may introduce response bias, and the implementation in only two practices, which may limit generalizability. Future studies should incorporate objective measures of impact and expand to additional HBPC sites to further evaluate scalability and broader applicability. This curriculum builds on existing dementia care frameworks by directly addressing the unique needs and constraints of HBPC environments. It also provides a replicable educational template for integrating structured dementia support into home-based services, where traditional primary care models may fall short. Future iterations of the curriculum should continue to adapt content and delivery based on learner feedback and explore mechanisms for broader dissemination across HBPC programs nationally. Conclusion The Dementia Care Quality at Home (DCQH) curriculum demonstrated that a structured, team-based educational model can successfully translate dementia care best practices into the home-based primary care setting. Learners gained confidence and competency in delivering dementia-focused interventions, and practices reported stronger interdisciplinary alignment and communication. Most importantly, caregivers experienced the benefits of tailored, structured support in managing the complex needs of PLWD. These findings support the potential of DCQH as a scalable and adaptable model for improving dementia care education in HBPC programs. Continued refinement of the curriculum based on learner feedback, and evaluation of long-term outcomes for caregivers and patients, will be critical for sustained integration and broader dissemination. Declarations Ethics approval and consent to participate This study was approved by the Massachusetts General Brigham Institutional Review Board (2022P003057) and was registered with ClinicalTrials.gov NCT05849259. All human participants provided verbal informed consent to participate. This study adhered to the Declaration of Helsinki protocols. Funding declaration This work was funded by the RRF Foundation for Aging under fund number (2021-467) Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to the confidentiality of our study participants, but are available from the corresponding author on reasonable request. Consent for publication Not Applicable Competing interests Dr. Leff serves on the clinical advisory boards of MedZed (a California-based entity that provides social and medical care services in patients’ homes usually under arrangements with Medicare Advantage Plans) and Patina Health (provides home-based primary care services). Author contributions CR, BL, OS developed the curriculum and performed the training synchronously and asynchronously MS, AT completed data collection and analysis Acknowledgements Not applicable References Ornstein KA, Leff B, Covinsky KE, Ritchie CS, Federman AD, Roberts L, et al. Epidemiology of the Homebound Population in the United States. JAMA Intern Med. 2015;175(7):1180. Datta R, Fried T, O’Leary JR, Zullo AR, Allore H, Han L, et al. National Cohort Study of Homebound Persons Living With Dementia: Antibiotic Prescribing Trends and Opportunities for Antibiotic Stewardship. Open Forum Infect Dis. 2022;9(9):ofac453. Possin KL, Merrilees JJ, Dulaney S, Bonasera SJ, Chiong W, Lee K, et al. Effect of Collaborative Dementia Care via Telephone and Internet on Quality of Life, Caregiver Well-being, and Health Care Use: The Care Ecosystem Randomized Clinical Trial. JAMA Intern Med. 2019;179(12):1658. Forester BP, Vogeli C, Flom M, Donelan K, Vienneau M, Drury M, et al. A Pilot Trial of CRESCENT in a Large Academic Healthcare System: A CaReEcoSystem Primary Care Embedded DemeNtia Treatment. Am J Geriatric Psychiatry Open Sci Educ Pract. 2024;2:19–31. Ritchie C, Leff B, Sy M, Thacker A, Donelan K, Forester B et al. Feasibility and Acceptability of a Clinician-Caregiver Co-Designed Dementia Care Intervention for Home-Based Primary Care. J Am Geriatr Soc. 2025. Adams NE. Bloom’s taxonomy of cognitive learning objectives. J Med Libr Assoc. 2015;103(3):152–3. Sy M, Thacker A, Sheehan OC, Leff B, Ritchie CS. Caring for caregivers and persons living with dementia under home-based primary care: protocol for an interventional clinical trial. Pilot Feasibility Stud. 2024;10:28. Wiltsey Stirman S, Baumann AA, Miller CJ. The FRAME: an expanded framework for reporting adaptations and modifications to evidence-based interventions. Implement Sci. 2019;14(1):58. Thacker A, Sy M, Leff B, Ritchie CS, Sheehan OC. Stakeholder Engagement to Inform and Refine an Existing Dementia Care Model in Home-Based Primary Care: The Co-Creation of Dementia Care Quality at Home. J Appl Gerontol. 2025;07334648251317301. Nevedal AL, Reardon CM, Opra Widerquist MA, Jackson GL, Cutrona SL, White BS, et al. Rapid versus traditional qualitative analysis using the Consolidated Framework for Implementation Research (CFIR). Implement Sci. 2021;16(1):67. Albrecht T, Schroeder M, LeCaire T, Endicott S, Marschall K, Felten K, et al. Training dementia care professionals to help caregivers improve the management of behavioral and psychological symptoms of dementia using the DICE Approach: A pilot study. Geriatr Nurs. 2022;48:74–9. Jennings LA, Palimaru A, Corona MG, Cagigas XE, Ramirez KD, Zhao T, et al. Patient and caregiver goals for dementia care. Qual Life Res. 2017;26(3):685–93. Fazio S, Pace D, Flinner J, Kallmyer B. The Fundamentals of Person-Centered Care for Individuals With Dementia. Gerontologist. 2018;58(suppl1):S10–9. Auerbach AD, Landefeld CS, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med. 2007;357(6):608–13. Additional Declarations No competing interests reported. Supplementary Files Appendix1AsychronousModules.pdf Appendix4SkillBuilding2.pptx Appendix3SkillBuilding1.pptx Appendix2AsychronousLearningFeedback.docx Appendix5DCQHPracticestafffocusgroupguidedocx.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 12 Feb, 2026 Reviews received at journal 27 Jan, 2026 Reviewers agreed at journal 24 Jan, 2026 Reviews received at journal 22 Jan, 2026 Reviewers agreed at journal 22 Jan, 2026 Reviews received at journal 24 Dec, 2025 Reviewers agreed at journal 12 Dec, 2025 Reviewers invited by journal 12 Dec, 2025 Editor assigned by journal 08 Dec, 2025 Editor invited by journal 18 Nov, 2025 Submission checks completed at journal 16 Nov, 2025 First submitted to journal 16 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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7.5 million older adults in the United States are homebound.(1)\u0026nbsp;Between 40-80% of homebound older adults have dementia, which imposes a significant burden not only on patients but also on their caregivers, who frequently experience high levels of stress, anxiety, and reduced emotional well-being.(2)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHomebound older adults’ access to ambulatory office-based primary care is often limited. Home-based primary care (HBPC) provides comprehensive, longitudinal medical care delivered by an interdisciplinary team including physicians, nurse practitioners, nurses, social workers and others directly in patients’ homes. It is designed for individuals who are homebound. Given that the prevalence of dementia among homebound older adults is approximately 50%, HBPC practices must be equipped to provide high-quality dementia care that supports both patients and caregivers.\u003c/p\u003e\n\u003cp\u003eExisting dementia care models, such as Care Ecosystem and its adapted version, CRESCENT, were developed for and have demonstrated benefit in office-based primary care by implementing standardized assessments, evidence-based interventions, and team-based case conferencing.(3,4)\u0026nbsp;These models have improved patient quality of life, reduced caregiver burden, and enhanced clinician competency in dementia care. HBPC differs significantly from office-based care, and existing models require significant adaptation to be effective in HBPC where the prevalence of dementia is much higher and the clinical workflows and practice resources vary significantly compared to office-based practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo bridge this gap, we developed and tested the feasibility and acceptability of the Dementia Care Quality at Home (DCQH) care model to deliver comprehensive, person-centered dementia care by HBPC practices.(5) As part of DCQH, we developed a structured curriculum to train HBPC clinicians and staff in delivering dementia care. The goal of this paper is to describe the development and evaluation of the DCQH curriculum. This curriculum was intended to optimize dementia care for homebound older adults receiving HBPC by improving the knowledge, skills, and collaborative methods among providers and staff in HBPC practices and to support the caregivers of people living with dementia (PLWD).\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cu\u003eOverview\u0026nbsp;\u003c/u\u003e\u003cbr\u003e\u0026nbsp;Learners\u003c/p\u003e\n\u003cp\u003eThe targeted learners for the curriculum were HBPC clinicians (physicians, nurse practitioners, nurses, social workers) and staff (receptionists, schedulers, XXX) in two HBPC practices in which the DCQH was pilot tested for feasibility and acceptability. Each practice designated personnel to participate in the pilot study and engage with the curriculum. Learners were expected to have prior experience of caring for PLWD and their care partners through their experience in HBPC. The curriculum employed a standardized approach across HBPC practices.\u003c/p\u003e\n\u003cp\u003eLearning Goals\u003c/p\u003e\n\u003cp\u003eThe learning goals of this curriculum were designed using Bloom’s Taxonomy to promote progressive skill development from foundational knowledge to applied clinical practice.(6)\u0026nbsp;Learning goals were conceived at the individual learner level and at the practice level. After completion of the curriculum, individual learners were expected to be able to: 1) describe key aspects of dementia and dementia care 2) conduct standardized assessments and prioritize relevant care challenges to be addressed, and 3) deliver care using structured dementia care modules to caregivers of PLWD. By the end of this curriculum, HBPC practices were expected to be able to 1) implement a standardized strategy for dementia care management appropriate to the workflows of the HBPC practice and 2) support caregivers of people living with dementia through a structured care model.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCurriculum Components and Training\u003c/u\u003e\u003cbr\u003e\u0026nbsp;There were two major components of the curriculum\u003c/p\u003e\n\u003cp\u003e1. Asynchronous training\u003c/p\u003e\n\u003cp\u003eThe asynchronous training comprised 12 video modules (8 required and 4 optional) (Appendix 1) on key issues in dementia and dementia care adapted to home-based care to be completed at a time convenient for each learner. The total time across all required and optional modules was 2 hours and 38 minutes and average video module length was 13 minutes long. Table 1 depicts modules topics and associated learning goals.\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eSynchronous training\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eDCQH adapted the Care Ecosystem dementia care model and its clinician-oriented adaptation, CRESCENT for the HBPC setting.(7)\u0026nbsp;Using the FRAME adaptation framework, the program was designed through stakeholder engagement to ensure relevance, usability, and integration into HBPC workflows.(8,9)\u0026nbsp;DCQH retained three core components from Care Ecosystem:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eA structured baseline needs assessment for PLWD and their caregivers.\u003c/li\u003e\n \u003cli\u003eSix dementia care modules, prioritized based on needs assessment findings: medication management, safety, behavior management, decision-making, caregiver well-being, and community resources. Each module provided specific structured guidance on a) assessment, b) management strategies, c) caregiver-focused resources, adapted for the HBPC setting.\u003c/li\u003e\n \u003cli\u003eA biweekly, team-based case conference for discussing patient needs and intervention-related learnings.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe synchronous training comprised two 90-minute live sessions over Zoom video conference with trainers and the entire practice clinical and non-clinical staff that would be involved in delivering DCQH care. The first live synchronous training session, “Skill Building and Support Session 1,” with a PowerPoint presentation (Appendix 2), included in-depth information about the role of a learner, the needs assessment, the structure and components of a module, and a simulation of how to prioritize modules for implementation with a patient based on data obtained from the needs assessment. The second live synchronous training session “Skill Building and Support- Session 2” with a PowerPoint presentation (Appendix 3) provided in-depth reviews of each DCQH care module with details on implementation including a step-by-step simulation of conducting a module with a caregiver and patient in the home.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eImplementation in Clinical Practice\u003c/u\u003e\u003cbr\u003e\u0026nbsp;HBPC practices designated at least one\u0026nbsp;dementia-trained clinician to\u0026nbsp;lead DCQH integration into the practice. Training for all participating clinicians and staff included asynchronous training, live synchronous modules, and ongoing support.\u003c/p\u003e\n\u003cp\u003eHBPC staff trained in DCQH conducted the baseline needs assessment in the home. Direct observation of the home environment and caregiver-PLWD interactions supplemented the assessment. Following completion of the needs assessment, HBPC clinicians engaged caregivers in a prioritization discussion to determine the order in which to implement modules with the caregiver over time. Learners (trained HBPC staff) delivered care modules to caregivers and patients in the home setting based on their clinical workflow of home visits over the subsequent months.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMeasures\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAt the end of each asynchronous module, all learners completed a learning assessment (Appendix 4). This assessment included a mix of Likert scale, multiple choice, and open response questions: “on a scale of 1-10, how much did this session help you?”, “Tell us about the level of detail (not enough, just enough, or too much) and “How much time did it take you to complete this training” (not enough, just enough, or too much). Open responses included “Were there any other topics that you would have liked for us to cover during this module” and “What was your biggest takeaway/learning from this presentation?” The research team quantitatively analyzed the Likert scale and multiple-choice answers and qualitatively coded open responses to generate key takeaways. The Likert scale scores (1-10) and key learnings are present in Table 1.\u003c/p\u003e\n\u003cp\u003eThe research team conducted follow-up surveys for learners after the completion of the intervention implementation in clinical practice. To assess the learners' ability to conduct and complete standardized assessments and prioritize relevant challenges, the team documented the number of assessments conducted and assessed the fidelity of learners in conducting the standardized learning assessments with caregivers in the home setting.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Five de-identified baseline needs assessments and one of each of the 6 care modules were randomly selected from each site for fidelity evaluation. The assessments and care modules were reviewed by study team members (MS, AT). Fidelity was rated as complete if all elements of the baseline needs assessment and the modules\u0026nbsp;were completed\u0026nbsp;or\u0026nbsp;partially\u0026nbsp;completed (some but not all elements were completed).\u003c/p\u003e\n\u003cp\u003eTo assess the learners’ ability to\u0026nbsp;deliver structured care modules to caregivers of people living with dementia, we documented the number of total modules conducted by each practice and assessed the fidelity of learners delivering care modules with caregivers in the home setting. To measure the fidelity of assessments and modules, we obtained a random sample of 10 completed assessments and 12 completed modules from practice sites.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition to the follow-up survey, HBPC practice staff participated in a focus group (one 1-hour focus group per site) to share qualitative data on their experience during the training and implementation of the DCQH intervention (Appendix 5). The focus groups were analyzed using deductive live rapid data analysis during focus groups.(10) \u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cu\u003eLearners-level results:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e21 learners (3 MDs, 10 NPs, 3 RNs, 3 SWs, 2 administrative staff members) from two HBPC practices completed training and the post-curriculum follow-up survey. Participants\u0026apos; scores regarding how much the module helped them, separated by training module, and a qualitative response summary, are depicted in Table 1. On average, scores for the required modules were 9.21/10 and 7.42/10 for\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ethe optional modules. After module completion, learners highlighted a stronger understanding of dementia pathophysiology, dementia subtypes, medication management, caregiver needs, safety planning, behavior strategies, and decision-making capacity and finances. Learners also stated that the optional modules reinforced the importance of early planning for guardianship, avoiding unnecessary hospitalizations, prioritizing comfort in advanced dementia, and connecting veterans to underused benefits.\u003c/p\u003e\n\u003cp\u003eNineteen learners self-reported a total of 50 completed assessments and prioritization of module order (100% completion rate). However, only 70% of audited baseline assessments were fully completed. Thirteen learners delivered a total of 256 modules, and 92% of audited modules were fully completed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePractice-level results:\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eDuring the post-intervention focus groups, practices reported that the DCQH training and case conferences effectively standardized dementia care knowledge across interdisciplinary team members.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026ldquo;It\u0026rsquo;s truly an [interdisciplinary] team, and everybody\u0026rsquo;s really focused on: How do we become more efficient, and how do we serve our patients better, and how do we do our job better, as well as, hopefully, do our job more efficiently, so it doesn\u0026rsquo;t leak out into our personal lives? (ID 1)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I definitely think how we structured it really helped, too, that we really took it as like a whole team approach, um, and that it wasn\u0026rsquo;t just like one or two people doing the modules for all the patients? That we really were mindful about splitting everything as evenly as possible, and, um, you know, having people from different disciplines participate\u0026rdquo; (ID 4)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I think it\u0026rsquo;s good to have it standardized that everybody on your team go through them, so we\u0026rsquo;re all working with the same background\u0026rdquo; (ID 5)\u003c/li\u003e\n \u003cli\u003e\u0026quot;I do feel like the meetings with the other practice were helpful. Like, I learned some pearls and tips and tricks from the \u0026lt;State\u0026gt; team, from the \u0026lt;City\u0026gt; team.\u0026quot;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis uniformity in training fostered a shared language and understanding of dementia care practices, promoting a more cohesive and collaborative approach to patient management. Providers noted that this alignment improved team communication and contributed to more consistent and coordinated care delivery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCaregivers of people living with dementia expressed appreciation for having dedicated time outside of routine medical appointments to focus on dementia-specific concerns.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026ldquo;Making the time and making it personal... as far as, not only did we care for our population, but also, that we\u0026rsquo;re taking interest in them, and just going, above and beyond in a sense\u0026rdquo; (ID 7)\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;I got the sense that it made them feel like we were doing something special for them...\u0026ldquo;We\u0026rsquo;d like you to participate in this special thing...\u0026quot; And I got the sense, they were very appreciative.\u0026rdquo; (ID 9)\u003c/li\u003e\n \u003cli\u003e\u0026quot;You know, the-the materials that you gave us, the fact that we could pick and choose and customize a little bit for the patient based on what we discussed in the, um, checklist, uh, that-that was helpful.\u0026quot; (ID 4)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eLearners found the structured case conferences helpful for addressing questions, learning tips from other practices on managing dementia related issues in the home, and understanding each other\u0026apos;s workflows and bandwidth to address assessment and module completion.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\" width=\"804\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eTable 1: Learning Goals, Scores, and Key Takeaways for each Asynchronous Training Module\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9104%;\"\u003e\n \u003cp\u003eTraining Module\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3134%;\"\u003e\n \u003cp\u003eLearning Goals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4478%;\"\u003e\n \u003cp\u003eHelp score [1-10]*\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAverage, SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.3284%;\"\u003e\n \u003cp\u003eSummary of Key Takeaways\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eREQUIRED (n=21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9104%;\"\u003e\n \u003cp\u003eDementia Basics Part 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3134%;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eDescribe the functional characteristics of different parts of the brain and how they relate to symptoms of dementia\u003c/li\u003e\n \u003cli\u003eDescribe the main theory for what causes dementia\u003c/li\u003e\n \u003cli\u003eDescribe why new biomarker tests are being developed to improve diagnosis of dementia\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4478%;\"\u003e\n \u003cp\u003e8.57, 1.67\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.3284%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLearners appreciated the clear review of dementia pathophysiology, stages, and brain structure, especially with visuals linking brain regions to specific symptoms and disease variants.\u003c/li\u003e\n \u003cli\u003eThe training reinforced that different types of dementia have distinct causes, behaviors, and symptoms, and highlighted the modest role of available treatments in slowing cognitive decline without curing the disease.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9104%;\"\u003e\n \u003cp\u003eDementia Basics Part 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3134%;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eDescribe symptoms that characterize vascular dementia\u003c/li\u003e\n \u003cli\u003eRecognize modifiable risk factors for vascular dementia\u003c/li\u003e\n \u003cli\u003eReview common medications used for people with vascular dementia\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4478%;\"\u003e\n \u003cp\u003e9.29, 1.27\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.3284%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLearners appreciated the clear distinctions between dementia subtypes and the importance of subtype-specific management.\u003c/li\u003e\n \u003cli\u003eLearners valued reminders about modifiable risk factors and how different dementias affect symptoms and caregiving needs.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9104%;\"\u003e\n \u003cp\u003eMedications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3134%;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eDescribe an adverse drug reaction\u003c/li\u003e\n \u003cli\u003eProvide a brief overview of selected guidelines related to geriatric therapy (Beers List, START and STOPP criteria)\u003c/li\u003e\n \u003cli\u003eIdentify medications used for common problems in dementia\u003c/li\u003e\n \u003cli\u003eUnderstand the expected benefit of medications for dementia,\u003c/li\u003e\n \u003cli\u003eDescribe dosing and monitoring for cholinesterase inhibitors and memantine\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4478%;\"\u003e\n \u003cp\u003e8.95, 1.31\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.3284%;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;The new approved medications for dementia have a very modest benefit.\u0026rdquo;\u003c/li\u003e\n \u003cli\u003eLearners understood that there are different medications for different types of dementia and adverse effects of certain medications.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9104%;\"\u003e\n \u003cp\u003eCaregiver Wellbeing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3134%;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eUnderstand the negative and positive impact that dementia can have on the family caregiver in terms of their physical health, mood, financial wellbeing\u003c/li\u003e\n \u003cli\u003eIdentify at least two reasons why a caregiver might enjoy or find meaning in being a caregiver\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4478%;\"\u003e\n \u003cp\u003e9.10, 1.38\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.3284%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLearners appreciated the emphasis on treating caregivers as integral members of the care team, highlighting both the challenges and the positive aspects of caregiving and the need for proactive support and care planning.\u003c/li\u003e\n \u003cli\u003eThere was strong recognition of the importance of monitoring caregiver well-being, providing resources, and using dementia-trained clinicians to identify and address caregiver needs systematically.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9104%;\"\u003e\n \u003cp\u003eSafety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3134%;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eRecognize five key and common home safety risks associated with dementia\u003c/li\u003e\n \u003cli\u003eIdentify four strategies for reducing safety risks for persons with dementia\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4478%;\"\u003e\n \u003cp\u003e9.28, 1.27\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.3284%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCaregivers and providers must move beyond \u0026quot;hope\u0026quot; by proactively assessing and planning for home safety risks to prevent emergencies and support safer aging in place.\u003c/li\u003e\n \u003cli\u003eSimple yet critical interventions\u0026mdash;like securing furniture, removing locks, using safety checklists, and educating caregivers\u0026mdash;can significantly reduce fall risks and accidents for people living with dementia.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9104%;\"\u003e\n \u003cp\u003eBehavior Management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3134%;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eUnderstand that behavior symptoms correlate with areas of brain damage\u003c/li\u003e\n \u003cli\u003eRecognize five unmet needs that may contribute to behavior symptoms\u003c/li\u003e\n \u003cli\u003eIdentify five potential environmental triggers for behavior symptoms\u003c/li\u003e\n \u003cli\u003eIdentify three caregiver factors that contribute to behavior symptoms\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4478%;\"\u003e\n \u003cp\u003e9.14, 1.35\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.3284%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eBehavioral symptoms in dementia are often influenced by environmental factors, caregiver responses, and unmet needs, and can frequently be managed effectively through non-pharmacologic strategies like the DICE approach before turning to medications.(11)\u003c/li\u003e\n \u003cli\u003eUnderstanding the differences between dementia and delirium, and emphasizing systematic, empathetic communication is crucial for better caregiver support and patient outcomes.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9104%;\"\u003e\n \u003cp\u003eDecision Making\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3134%;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eUpon completion of this training module, you will be able to:\u003c/li\u003e\n \u003cli\u003eApply ethical/legal standards of capacity to your work\u003c/li\u003e\n \u003cli\u003eExplain how to assess for capacity and who can make determinations of capacity, and on what grounds\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4478%;\"\u003e\n \u003cp\u003e9.28, 1.27\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.3284%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLearners emphasized that advance care planning is a continuous process, not a one-time document, and should begin early while patients still have decision-making capacity.\u003c/li\u003e\n \u003cli\u003eThere was appreciation for clarifying that capacity is task-specific (not global), fluctuates over time, and differs from legal competence, with guidance on assessing capacity and identifying appropriate surrogates.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9104%;\"\u003e\n \u003cp\u003eFinancial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3134%;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eDescribe the qualities of a good financial caregiver\u003c/li\u003e\n \u003cli\u003eUnderstand why it is important for a person with dementia to have legally-recognized financial caregivers.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4478%;\"\u003e\n \u003cp\u003e9.05, 1.43\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.3284%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLearners emphasized the critical need for early financial planning, encouraging patients to appoint a trusted financial power of attorney (POA) while they still have capacity to prevent future legal and financial hardships.\u003c/li\u003e\n \u003cli\u003eThere was an appreciation for learning about the differences between financial and healthcare planning, various account options, and the legal distinctions between capacity and competency.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003eOPTIONAL\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9104%;\"\u003e\n \u003cp\u003eGuardianship*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3134%;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eDefine guardianship\u003c/li\u003e\n \u003cli\u003eName at least two ways to help avoid guardianship\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4478%;\"\u003e\n \u003cp\u003e7.17, 1.83\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003en=6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.3284%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eAppointing guardianship earlier is better to avoid complications later in the disease process: \u0026ldquo;the earlier the better\u0026rdquo;.\u003c/li\u003e\n \u003cli\u003eGuardianship can be expensive and is not the best option if it can be avoided.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9104%;\"\u003e\n \u003cp\u003eHospitalizations*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3134%;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eDescribe why people with dementia are at increased risk of hospitalization\u003c/li\u003e\n \u003cli\u003eIdentify common risks and reasons for hospital admission among persons with dementia receiving home-based primary care\u003c/li\u003e\n \u003cli\u003eDescribe adverse outcomes of hospitalization for people with dementia\u003c/li\u003e\n \u003cli\u003eDescribe strategies for reducing unnecessary hospitalization among people with dementia receiving HBPC\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4478%;\"\u003e\n \u003cp\u003e7.50, 2.07\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003en=5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.3284%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eRecognizing the warning signs of delirium, providing caregiver education, and using claims-based data and flow charts are important strategies for managing dementia care.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9104%;\"\u003e\n \u003cp\u003eTube Feeding*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3134%;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eUnderstand most patients\u0026apos; progression from mild to moderate to advanced dementia\u003c/li\u003e\n \u003cli\u003eExplain why tube feeding is not recommended for patients with difficulty eating\u003c/li\u003e\n \u003cli\u003eExplain why we try to avoid hospitalization in advanced dementia\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4478%;\"\u003e\n \u003cp\u003e7.17, 2.32\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003en=6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.3284%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLearners understand that tube feeding in advanced dementia does not improve mortality outcomes.\u003c/li\u003e\n \u003cli\u003eIn advanced dementia care, prioritizing comfort over calorie count reflects a more compassionate, lifestyle-centered approach.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.9104%;\"\u003e\n \u003cp\u003eVA Benefits*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37.3134%;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eLearn the different types of benefits available\u0026nbsp;to veterans, including income benefits\u003c/li\u003e\n \u003cli\u003eUnderstand the basics of VA healthcare\u003c/li\u003e\n \u003cli\u003eKnow where to send veteran patients and families to get help with VA benefits\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.4478%;\"\u003e\n \u003cp\u003e7.83, 1.94\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003en=6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.3284%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLearners gained awareness that there are many underused benefits, such as home health aides and respite options, and service providers may need to guide caregivers to access these resources.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates that a structured dementia care curriculum adapted for the HBPC setting can be implemented and can improve the knowledge, skills, and collaborative practices of interdisciplinary teams while enhancing support for caregivers of PLWD. The DCQH curriculum was well-received by both groups of learners, supporting its utility as a scalable model for dementia care education in non-traditional care settings.\u003c/p\u003e\n\u003cp\u003eConsistent with prior work on the Care Ecosystem and CRESCENT models, learners reported that standardized training and case conferencing helped create a shared language and collaborative approach to dementia care delivery.(3,4)\u0026nbsp;This finding reinforces the importance of team-based education in dementia care, especially in HBPC settings where team members often operate autonomously. By creating consistency across providers, the curriculum supported more integrated and efficient care delivery, a known facilitator of quality outcomes in home-based care.(12)\u003c/p\u003e\n\u003cp\u003eParticipants also valued the flexibility and adaptability of the care modules, which allowed providers to tailor interventions to individual caregiver needs—a key principle of person-centered dementia care.(13)\u003c/p\u003e\n\u003cp\u003eChallenges to training implementation were primarily logistical, including scheduling barriers and a desire for more concise training materials. These challenges mirror findings from similar educational interventions in geriatric and dementia care, which often cite time constraints and workflow disruption as barriers to adoption.(14)\u0026nbsp;Streamlining modules and building in flexibility for delivery may further enhance uptake and sustainability across diverse practice settings.\u003c/p\u003e\n\u003cp\u003eStrengths of this study include its focus on a previously underexplored setting, home-based primary care (HBPC), and its implementation across two diverse, health-care delivery sites, one in Virginia, and one in Hawaii, allowing for insights into curriculum adaptability across varying contexts, health systems and populations. Additionally, the curriculum was open to all staff in the home-based primary care practice, both clinicians and non-clinicians, ensuring a consistent and comprehensive framework to assess outcomes on an individual learner and practice level.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLimitations include the use of self-reported data, which may introduce response bias, and the implementation in only two practices, which may limit generalizability. Future studies should incorporate objective measures of impact and expand to additional HBPC sites to further evaluate scalability and broader applicability.\u003c/p\u003e\n\u003cp\u003eThis curriculum builds on existing dementia care frameworks by directly addressing the unique needs and constraints of HBPC environments. It also provides a replicable educational template for integrating structured dementia support into home-based services, where traditional primary care models may fall short. Future iterations of the curriculum should continue to adapt content and delivery based on learner feedback and explore mechanisms for broader dissemination across HBPC programs nationally.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe Dementia Care Quality at Home (DCQH) curriculum demonstrated that a structured, team-based educational model can successfully translate dementia care best practices into the home-based primary care setting. Learners gained confidence and competency in delivering dementia-focused interventions, and practices reported stronger interdisciplinary alignment and communication. Most importantly, caregivers experienced the benefits of tailored, structured support in managing the complex needs of PLWD. These findings support the potential of DCQH as a scalable and adaptable model for improving dementia care education in HBPC programs. Continued refinement of the curriculum based on learner feedback, and evaluation of long-term outcomes for caregivers and patients, will be critical for sustained integration and broader dissemination.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Massachusetts General Brigham Institutional Review Board (2022P003057) and was registered with ClinicalTrials.gov NCT05849259. All human participants provided verbal informed consent to participate. This study adhered to the Declaration of Helsinki protocols.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was funded by the RRF Foundation for Aging under fund number (2021-467)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to the confidentiality of our study participants, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Leff serves on the clinical advisory boards of MedZed (a California-based entity that provides social and medical care services in patients’ homes usually under arrangements with Medicare Advantage Plans) and Patina Health (provides home-based primary care services).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCR, BL, OS developed the curriculum and performed the training synchronously and asynchronously\u003c/p\u003e\n\u003cp\u003eMS, AT completed data collection and analysis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOrnstein KA, Leff B, Covinsky KE, Ritchie CS, Federman AD, Roberts L, et al. Epidemiology of the Homebound Population in the United States. JAMA Intern Med. 2015;175(7):1180.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDatta R, Fried T, O\u0026rsquo;Leary JR, Zullo AR, Allore H, Han L, et al. National Cohort Study of Homebound Persons Living With Dementia: Antibiotic Prescribing Trends and Opportunities for Antibiotic Stewardship. Open Forum Infect Dis. 2022;9(9):ofac453.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePossin KL, Merrilees JJ, Dulaney S, Bonasera SJ, Chiong W, Lee K, et al. Effect of Collaborative Dementia Care via Telephone and Internet on Quality of Life, Caregiver Well-being, and Health Care Use: The Care Ecosystem Randomized Clinical Trial. JAMA Intern Med. 2019;179(12):1658.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForester BP, Vogeli C, Flom M, Donelan K, Vienneau M, Drury M, et al. A Pilot Trial of CRESCENT in a Large Academic Healthcare System: A CaReEcoSystem Primary Care Embedded DemeNtia Treatment. Am J Geriatric Psychiatry Open Sci Educ Pract. 2024;2:19\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRitchie C, Leff B, Sy M, Thacker A, Donelan K, Forester B et al. Feasibility and Acceptability of a Clinician-Caregiver Co-Designed Dementia Care Intervention for Home-Based Primary Care. J Am Geriatr Soc. 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdams NE. Bloom\u0026rsquo;s taxonomy of cognitive learning objectives. J Med Libr Assoc. 2015;103(3):152\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSy M, Thacker A, Sheehan OC, Leff B, Ritchie CS. Caring for caregivers and persons living with dementia under home-based primary care: protocol for an interventional clinical trial. Pilot Feasibility Stud. 2024;10:28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWiltsey Stirman S, Baumann AA, Miller CJ. The FRAME: an expanded framework for reporting adaptations and modifications to evidence-based interventions. Implement Sci. 2019;14(1):58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThacker A, Sy M, Leff B, Ritchie CS, Sheehan OC. Stakeholder Engagement to Inform and Refine an Existing Dementia Care Model in Home-Based Primary Care: The Co-Creation of Dementia Care Quality at Home. J Appl Gerontol. 2025;07334648251317301.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNevedal AL, Reardon CM, Opra Widerquist MA, Jackson GL, Cutrona SL, White BS, et al. Rapid versus traditional qualitative analysis using the Consolidated Framework for Implementation Research (CFIR). Implement Sci. 2021;16(1):67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlbrecht T, Schroeder M, LeCaire T, Endicott S, Marschall K, Felten K, et al. Training dementia care professionals to help caregivers improve the management of behavioral and psychological symptoms of dementia using the DICE Approach: A pilot study. Geriatr Nurs. 2022;48:74\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJennings LA, Palimaru A, Corona MG, Cagigas XE, Ramirez KD, Zhao T, et al. Patient and caregiver goals for dementia care. Qual Life Res. 2017;26(3):685\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFazio S, Pace D, Flinner J, Kallmyer B. The Fundamentals of Person-Centered Care for Individuals With Dementia. Gerontologist. 2018;58(suppl1):S10\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAuerbach AD, Landefeld CS, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med. 2007;357(6):608\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8001358/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8001358/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDementia is highly prevalent among the 7.5\u0026nbsp;million homebound older adults in the United States. Despite this high dementia prevalence, dementia care interventions and associated curricula developed to date have focused nearly exclusively on office-based primary care and have not been adapted to the unique care setting, staffing, and workflows of home-based primary care (HBPC). We developed and implemented a pilot study of the Dementia Care Quality at Home (DCQH) curriculum to train HBPC clinicians and staff in person-centered dementia care. The objective of this study is to evaluate the DCQH curriculum.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThe curriculum comprised 8 required and 4 optional asynchronous video modules, two 90-minute synchronous skill-building sessions focused on training for implementation of a standardized assessment, and six core dementia care modules through structured home visits, and monthly case conferences. Learners completed baseline assessments and care modules with patients and caregivers, followed by fidelity reviews and post-intervention focus groups. We assessed learners\u0026rsquo; knowledge via training questionnaires, completion rates, fidelity of assessments and modules, and the reported feasibility and acceptability of the curriculum using both quantitative and qualitative methodology.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTwenty-one HBPC clinician and staff learners completed training and post-curriculum surveys. Fifty assessments and 256 dementia care modules were successfully delivered, with 92% fidelity by audit. Learners qualitatively reported increased confidence in dementia care domains including symptom management, behavior strategies, caregiver support, and interdisciplinary collaboration. Focus groups highlighted improved team cohesion and consistent care delivery. Caregivers valued having structured time outside of traditional medical visits to address dementia-specific concerns.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e The DCQH curriculum improved knowledge, workflow integration, and interdisciplinary collaboration among HBPC teams, while offering caregivers enhanced support. This structured, scalable model shows promise for improving dementia care delivery in home-based settings and may serve as a framework for future training in geriatric care settings.\u003c/p\u003e","manuscriptTitle":"Dementia Care Quality at Home: A Dementia Care Curriculum for Home-Based Primary Care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-17 18:44:28","doi":"10.21203/rs.3.rs-8001358/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-12T16:24:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-27T17:01:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"56147060382875891885159520317068134729","date":"2026-01-24T22:35:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-22T21:26:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"234203377906617675718156959154175542437","date":"2026-01-22T17:32:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-24T22:47:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211880031323604788791361361840292920814","date":"2025-12-12T14:33:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-12T11:55:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-08T21:43:02+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-18T06:15:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-16T16:54:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-11-16T16:52:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2d60cdfe-1b55-4fc1-9cc2-e5e2c68f442f","owner":[],"postedDate":"December 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-15T10:11:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-17 18:44:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8001358","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8001358","identity":"rs-8001358","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}