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Evaluating the effectiveness and cost effectiveness of Dementia Care Mapping™ (DCM™) to enable person-centred care for people with dementia and their carers: A cluster randomised controlled trial in care homes.
Only a small number of studies have been conducted to see how effective Dementia Care MappingTM (DCM) is in care homes, and if it provides good value for money. None were carried out in the UK and some used researchers rather than care home staff to implement DCM. The DCM EPIC trial therefore looked at whether DCM was more effective and offered value for money compared to usual care in helping staff to implement person-centred care in care homes in the UK. We did this in a way that was as close to ‘real world’ delivery as possible.
Dementia Care Mapping™ (DCM) is a technique developed at the University of Bradford, which has been widely used for over 20 years in hospitals and care homes internationally, to help staff apply person-centred care in practice. DCM involves a cycle of training at least two staff working within care home to use the DCM tool. They brief the staff team about what will happen, then observe the experience of care from the point of view of people with dementia and feeding this back to the rest of the staff team. The staff then use this information to look at ways they can improve care and develop care and action plans. This process is carried out every four to six months so changes can be monitored and new improvements identified.
You can find out more about DCM from the University of Bradford website.
The approach
This study aimed to assess if Dementia Care MappingTM (DCM) is effective and cost effective at helping care home staff to reduce agitation and deliver improved outcomes in care home residents with dementia through implementing person-centred care. Improved outcomes include reductions in other behaviours staff may find difficult to support, reduced use of anti-psychotics and other sedative medications, reduced healthcare use, improved quality of life and improved quality of staff interactions with residents.
The study was a pragmatic (real world), cluster (multiple participants in one care home, known as a cluster) randomised controlled trial (RCT). For this, care homes were randomly assigned to either DCM, the intervention group, or to carry on with usual care, the control group. It commenced on 1 September 2013 and was completed on 31 December 2017, with write up and dissemination continuing into 2020.
The study recruited 50 care homes and 726 residents with dementia across West Yorkshire, London and Oxfordshire. After baseline data collection, 31 care homes were randomised to DCM and 19 to usual care, with data collection repeated at 6- and 16-months after randomisation. At 16-months we recruited a further 261 residents because nearly 50% of the original sample had died or moved away from the care home.
We collected data on resident outcomes such as agitation, other behaviours staff may find difficult to support, antipsychotic medication use, resident quality of life and the quality of staff communication with residents. Data were collected from residents, relatives and staff members.
We aimed to train two staff members in each DCM allocated home to use the method (trained DCM users are called ‘mappers’). We asked them to complete three full DCM cycles over the 16-month period. While the aim of a pragmatic trial is to implement DCM as close to real world delivery as possible, we included a range of additional supports for care home mappers to help implementation, which would be feasible to put in place if DCM was found to be effective. This included skills and qualities selection criteria for mappers, providing standardised documents to complete each DCM component, providing an external expert in use of DCM to help mappers deliver their first cycle, ongoing support by e-mail/phone from a DCM intervention lead and providing text message prompts to remind mappers to complete each cycle.
After final data collection was complete we interviewed mappers, managers, staff, residents and relatives in 18 of the care homes that had been allocated to use DCM. The homes represented a range of implementation from none to three cycles. We asked them about their experiences of implementing DCM and the barriers and facilitators to this.
the impact
The study found that there were no benefits of DCM over usual care for any outcomes and that DCM was not good value for money. Implementation of DCM was poor with only 26% of care homes completing 2 or 3 DCM cycles. Just under a quarter of homes (22%) did not complete one full cycle and 52% only completed their first cycle supported by the expert mapper.
Many mappers and some managers and staff felt they had gained benefits from using DCM and provided examples of the ways they felt DCM had helped them to identify areas to improve care practice. These included improved communication, providing more activities and increased staff confidence. However, there were many barriers to implementing DCM including how complex and time consuming care homes found the tool to implement, mappers lacking the confidence and skills to implement DCM and lead practice change, a lack of time and resources to use DCM, lack of ongoing manager support, lack of wider staff engagement and the additional pressures that taking part in a research study brought with it.
We concluded that the majority of standard care homes were unlikely to have the time and resources to implement DCM and therefore it should not be recommended on a widespread basis to help implement person-centred care. Different methods of implementation need to be considered that do not involve leadership by care home staff.
An overview of the DCM EPIC trial
The involvement of people with the dementia in the DCM EPIC trial
Why is research in care homes important?
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