Structure and Format of the Savvy Classes

Part One, Section D: Structure and Format of the Savvy Classes

How the Savvy Caregiver Program is Structured

The program generally entails six two-hour meetings, held weekly. The chart on the next page provides an overview of the material covered in each of the sessions. You will note that, beginning with the second session, each week begins with a review of the previous week’s materials and with the home assignments that were given. This time is key in the program. It gives participants a chance to ask questions about material you covered in the previous week(s) or in the readings and to take credit for their accomplishments. It also makes it clear that they know a great deal about caregiving — they are experts and are getting even more expert at their role.

The home assignments are not meant to be oppressive, and there is no expectation that you, as program leader, will “enforce” the completion of homework (no grades are given). But practice is an important component of the workshop’s success — as well as getting feedback (coaching) on the experiences they had when trying out the ideas presented in the workshop. Having caregivers try to apply their learning at home is, again, a strategy that is used in clinical training: it isn’t enough to read about a skill. The learner only acquires both the skill and the outlook that goes with the skill by putting it into use over and over and having someone — in this case you and the group — with whom to debrief and by whom to be coached.

WEEK ONE

Introduction to the program and program material
Introduction of participants
Exploring dementia — facts about dementing disorders
The impact of Alzheimer’s and other progressive dementias on thinking and the implications of these losses for Savvy Caregiving
Introduction to the resource materials for the program

WEEK TWO

Review of last week’s materials, readings, and homework
Caregiver self-care: Recognizing and dealing with Feelings
Confusion: the central problem in dementing diseases
The implication of Confusion for Savvy Caregiving
A simple Model of Behavior
Communicating with Confusion: Dealing in Emotional Truth Taking Control

WEEK THREE

Review of last week’s materials, readings, and homework
Contented Involvement: A reasonable goal for caregiving
The concept of Fit: Matching tasks and activities to abilities
Performance — the Important Elements
Introducing a Staging System

WEEK FOUR

Review of last week’s materials, readings, and homework
Anchors of Contented Involvement — Structure and Support
Linking Disease Stages to Structure and Support
Basic Communication Techniques
Developing strategies for common behavioral problems

WEEK FIVE

Review of last week’s materials, readings, and homework
Applying Savvy Caregiver principles to day-to-day life: using the Anchors to design daily tasks
Introducing a Model for Decision-Making

WEEK SIX

Review of last week’s materials, readings, and homework
Types of Caregiving Families
Strengthening Families as Resources of Care
Review of Savvy Caregiver Program

The first four weeks of the program are very content-laden. The sessions — through exercises, handouts and talks — will give participants a great deal of information and a great deal to try out and think about. This information will be reinforced by — and added to — by other resource material, particularly the Caregiver’s manual (and also the optional media-based (CD-ROM/ Internet) resource, Alzheimer’s Caregiving Strategies — explained later in the introduction). The design of the program is such that the expectation for caregiver performance — for the demonstration that they are taking all this information in and are “getting it” in such a way that they are able to put it into use in their caregiving — is deferred. While you will want to urge and prod them to do their homework, the real payoff doesn’t usually come until the fifth and sixth weeks. That is when most caregivers begin to show that they have integrated at least the main ideas of the workshop.

This can be challenging, from your perspective as a leader. In our experience, there are times when the group seems to be floundering during its early weeks. Participants might seem confused or unconvinced. Some will tell you that they “get it,” but, when you hear them talking, it is clear that they don’t yet understand the main idea. You’ve got to rely on the material and be patient. Don’t be concerned if the group seems flat, even in the middle weeks. Just keep at it. They will get it and will show you they get it — even if it’s only in the sixth week that they do so.

The Role of the Program Leader

The program proceeds through a series of exercises you will lead and brief talks you will provide. The program has been designed to take advantage of your experience with caregivers, caregiver support groups, and/or other group and teaching situations. The major skills you need to lead the program are those of group facilitation. If you bring expertise in the area of Alzheimer’s and dementia, that is a plus. The program materials supply the information participants need about the disease. The amount that you will be called upon to “lecture” about these things will be minimal.

When a talk is called for, the outline is provided in this guide and the content is fully given in the Caregiver’s Manual. Material is provided in the Trainer’s manual that may help you provide additional information and guidance or from which you can draw questions to use to help the sessions be more interactive. Exercises are structured and outlined in this guide. Any handout materials you might need are provided. Slides for the talks and exercises are included in the text of this Trainer’s Manual. Program participants are given a set of the slides in hard copy, so they can follow along and make notes as you use them in the sessions.

A great deal of the learning we expect caregivers to do will happen through the assigned work you will expect each participant to do outside of the group. It is important that caregivers not feel this as a performance pressure, but you should emphasize that the “homework” will add greatly to their learning. Caregivers will have several resources for the work outside of class:

The Caregiver’s Manual is the textbook for the program, and most of what happens in the program is covered in the manual. The order of the Caregiver’s Manual is roughly the same as the order of the materials presented in the sessions — at least as far as the backbone information on the impact of Alzheimer’s and managing daily life. The content is covered in the live sessions and in the manual, so you can direct caregivers to appropriate sections to review material and to read ahead. You, as leader, will have a copy of this manual and should read it carefully, use the ideas in it, and make reference to it. The Trainer’s Manual will provide specific page references to the Caregiver’s Manual when these are relevant for exercises or tasks. As mentioned, each participant receives a copy of all the slides used in the sessions. These slides — with room for notes — may be all the participants need to bring to the sessions. A number of worksheets and handouts are also provided.
Video Materials. A videotape accompanies the Trainer’s Manual. The video has three segments. The first segment captures persons at various stages of Alzheimer’s being directed by an occupational therapy aide to perform two common tasks: making a sandwich and folding towels. This segment is used in Session 3 when teaching the staging system used in the program. You may want to use portions of the segment in Session 4 when discussing the Anchors of Contented Involvement. The second segment of the video portrays a group of persons at various stages of Alzheimer’s, led by an occupational therapist, engaged in a common activity. The video can be an effective tool for illustrating the way in which a skilled clinician works to involve persons at varying stages in an activity. The third segment of the tape presents a talk by Dr. Marsha Lewis on the decision-making model that is taught in Savvy in Session 5. You can use this to replace a brief talk that you would provide on the decision-making model.
“Alzheimer’s Caregiving Strategies.” This interactive educational program is available either on-line or as a CD-ROM. This program was developed by the Veterans Administration Education Service. The program contains additional information relevant to the Savvy Caregiver Program. Much of the content about the impact of Alzheimer’s on the person, the Allen Level staging system, and strategies for caregiving parallels and reinforces the content of Savvy. There is additional video material in the program, including video of other persons with dementia completing the sandwich-making and towel-folding tasks. The producer was Richard Adelson, DDS, and the contributing authors included Ken Hepburn, PhD from the University of Minnesota (UMN), Melitta Maddux, RN, MS from the VA Geriatric Research, Education, and Clinical Center (GRECC), and Stan Smith, MD, MPH (UMN). This program can be obtained from the distributor, Healthcare Interactive, found at www.hcinteractive.com. The curriculum of the CD ROM and the Savvy Caregiver Program derives from research conducted at the University of Minnesota on family caregiver education programs called the Minnesota Family Workshop and Partners in Caregiving. Further information on that program and the results of that research can be found in the following articles:

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. The Gerontologist, 39(3), 299-309, and Hepburn, K, Lewis M, Narayan, S, Tornatore, J, Center, B, Lindstrom- Bremer, K. Partners in Caregiving: A psychoeducation program to reduce caregiver distress. Clinical Gerontologist, Sept., 2005.

Homework Assignments

Caregivers are given assignments — homework — after every program session. They will be asked to read sections of the Caregiver Manual (and optional assignments are given for viewing relevant sections of the Alzheimer’s Caregiving Strategies program). More importantly, they will be asked to apply what they have learned in the session in their work with the person at home. For example, they will be asked after Sessions 4 and 5 to design and structure tasks and activities the person might find involving and contenting and to apply behavior management principles to guide the person away from troubling behaviors. Participants will not achieve a sense of mastery about their new skills and knowledge unless they try them and experience comfort and success in their use. So it is important that they practice.

The other important thing that practice accomplishes is to provide caregivers with a sense of comfort in experimentation, a skill and a sense that they need to carry forward after the program ends. Many caregivers are extremely cautious about trying anything new or different with their person. The program gives them direction and permission to do so. One of the big lessons from the program should be that caregivers will develop a bigger repertoire if they try new things — and that even a failed experiment provides information that eventually leads to something that works and that can be added to the bag of tricks.

Home assignments may pose problems for some caregivers. For some, making time to come to the sessions may use up all the free time they have. For others, it may prove difficult to find time and place at home where they can be away from the person they care for. They may have a hard time being able to do the homework. This is a reality of caregiving. You can offer some suggestions that might help:

Encourage family participation. Have other family members help out while caregivers do their homework. Alternatively, have the homework be a group activity with the other family members.
Encourage them to follow along carefully in class and to keep the homework material handy — someplace where they can get to it quickly and easily. Then do it when they get the time.
Encourage them to remember the assignments. Even if they can’t do the reading or fill out the forms, right now, they should keep them in mind. Remember they are there and are meant to be a resource. They should make a deal with themselves to get these materials out when they feel the need for them.

Interaction With Family

A number of exercises specifically expect caregivers to interact with other family members. However, there is no intent to limit interaction to these specified times. Caregivers should be encouraged to bring family members to the program and/or to share the readings (and the Alzheimer’s Caregiving Strategies program) with them.

The Savvy Caregiver Program is often the first opportunity caregivers have had to see that there is a great deal they can learn and that they can access resources to help them. As the program progresses, and as caregivers become more comfortable with and confident in it, more and more questions will arise. The material itself will stimulate questions. For example, the material on staging in Session 3 (and in the optional interactive program) will likely involve a method of staging that most people have not heard of before. Similarly, the linkage between stages and strategies for designing tasks and activities (Session 4) is probably something they have not heard of before.

You as Leader

Because you are the group leader, questions will be addressed to you. Group leaders will be expected to follow four guidelines in addressing questions from caregivers.

Validate (and Clarify) the Question. Process the question. Be sure the person (as well as you) understands what they are asking. Recognize the importance of the question — encourage questions and the search for information. That, in itself, is an important caregiving strategy and is one mark of a savvy caregiver.
Stay within Your Own Expertise. Give the best answer you can from your own knowledge — but, if there are limits to that knowledge, make them known. (For instance, if asked about the effectiveness of Alzheimer’s drugs, you might respond, “Well I’m not a physician, but I do know that a lot of physicians are prescribing these and a lot of caregivers are satisfied with the results.”) Don’t guess and don’t try to wing it. If you are trying to reason through to something, based on your knowledge, let the group know this.
Try to Find Answers. Recognize and acknowledge when you don’t know an answer and — if you think it feasible — take it on yourself to search out the answer outside of the group. If you do say you’ll look for information, make note of this so that you can hold yourself accountable for seeking the answer and then reporting back on it.
Refer to Appropriate Disciplines. Make it clear that some answers might best come from experts in various fields. Physicians, nurse practitioners, and pharmacists can be sources of information about Alzheimer’s medications and medications that can be useful with some of the behaviors that can manifest themselves in Alzheimer’s and other diseases. The occupational therapy-based staging system presented in the Savvy Caregiver Program allows caregivers to estimate their person’s approximate stage; if they want a professional assessment that can provide an exact staging, they should be referred to an occupational therapist who knows the Allen Stages. The strategy material presented in Session 4 relies heavily on OT and nursing.

Preparing to Lead the Program

We have learned, from feedback from other program leaders, that it is essential to prepare a “lesson plan” for each session. The Trainer’s Manual gives you the structure of each session and, together with the Caregiver’s Manual, provides content material. However, it doesn’t work well to try to use the Trainer’s Manual as a sort of cookbook for leading the class. The best preparation— especially for the first time through the program—is to thoroughly digest each session’s intent and structure and to read all the material and then to use whatever teaching/leading strategy works best for you (note cards, an outline, etc.). This should become your program. The manuals give you the structure and content, but the way you lead is your own.

A Final Word

Participation is a key to success in the program. Another key is covering all the material. You may sometimes find these two at odds with each other. There is no easy or fixed answer to this problem: cover as much as possible. Many caregivers will enter the program either passively or reluctantly. Others will enter it thinking that it is another kind of support group. On of you big jobs will be to clarify the nature and purpose of the program and to draw the participants into it. Another big job will be to defer questions that are outside the scope of the training until after the session — to keep it from turning into a support group. Thus, your group skills will be paramount to the success of the program.

Keep in mind that much of this material is new to participants, and that most of them are learning a great deal in the program. When you see opportunities to do so, remind participants of things they learned. Also, if you see that something from an earlier session was incompletely understood, circle back to it and review it to be sure participants understand.”

Savvy is just one piece of instruction and support from which caregivers can benefit, and completing the program does not, in itself, prepare the caregiver for all that is to follow. From your experience, you will know of other programs that would be of benefit. We encourage you to refer caregivers into those. At the same time, we urge you to recognize the enormous power you have as a program leader, power that would enable you to use Savvy as a platform for other ideas you may deeply believe. Keep the Savvy program intact; teach it as it is presented; alter it only in small ways that are consistent with what the program is setting out to accomplish. But don’t hesitate to point caregivers in other directions after the program is over.

We’ve found it is helpful if the clinicians with whom caregivers are dealing know something about the Savvy program. It is helpful for clinicians to understand what caregivers are learning and to see that they, the caregivers, are strengthening their competence, based on a certain way of thinking about strategies for management. If clinicians and caregivers can share a common language and frame of reference about the disease and how the caregivers are handling it, those clinicians can provide invaluable on-going assistance. So share the program with clinicians.

Finally, the schedule (six two-hour sessions) isn’t set in stone. We know of one organizations that runs two six hour sessions to accommodate rural caregivers. Do what works.