Supporting Caregivers of The Aging Adult: A Program Evaluation

There is an ever-increasing burden on caregivers of individuals with cognitive illness as a result of the increasing number of older adults with dementia and Alzheimer's disease. Currently, St. John's County Florida offers three programs designed to provide support for caregivers of individuals with cognitive illness. This project evaluated the three programs as part of a program evaluation to determine the efficacy of program selection for sustainability. Utilizing the Center for Disease Control's (CDC) Program Evaluation Framework (PEF), a detailed and thorough evaluation review of the Power Tools for Caregivers, Savvy Caregiver, and an original threemodel program developed by the Council on Aging (COA) was conducted. The three programs currently in use were found to meet the requirements of a successful program per the CDC Program Evaluation Framework, and therefore, were recommended for continued use in assisting caregivers of individuals with cognitive illness. SUPPORTING CAREGIVERS OF THE AGING ADULT 4 Supporting Caregivers of the Aging Adult: A Program Evaluation Alzheimer’s disease was first diagnosed in the United States in 1906 (National Institute on Aging, 2017). There are over 50 million patients with cognitive illnesses in the world. In the United States, there are about six million individuals with cognitive illness (Centers for Disease Control [CDC], 2019). There are 16 million people in the United States that are caring for a loved one with a cognitive illness (Help Guide, 2022). Caregivers can be consumed with the burden of a loved one. The care of a family member can lead caregivers down a path of personal neglect that causes both mental and physical health problems (Caregiving in the US, 2020). Providing help or respite care is a large need among caregivers. There are various ways that they can provide help including education, engaging family members in activities, offering them a reprieve, and providing flexibility (Alzheimer’s Association, 2019). This program evaluation compared the effectiveness of the Savvy Caregiver program, Powerful Tools for Caregivers, and the three-module original program developed by the Council on Aging (COA) against the CDC's Program Evaluation Framework (1999) with the goal of determining suitability and efficacy for program selection for sustainability. Significance of the Practice Problem The practice problem that the program evaluation addressed was the growing population of caregivers of patients with cognitive illnesses that are experiencing caregiver stress in St Johns County, Florida. This issue is important because caregiver fatigue can cause complications for both the caregiver and the patient. There are several challenges the caregivers may face such as objective/subjective burden, psychological morbidity, social isolation, and financial difficulties (Nelson, 2021). High stress and burnout are common among caregivers of patients with cognitive illness. While there are a few resources to be found in the community (Alzheimer’s SUPPORTING CAREGIVERS OF THE AGING ADULT 5 Association, 2022a), there are not enough for the number of caregivers that need help. Research showed that interventions and resources could reduce both neuropsychiatric symptoms and the burden that caregivers feel (Cravello et al., 2021). According to the National Institute on Aging (2017), self-care is one of the most important interventions a caregiver can perform. Different ways that caregivers can engage in self-care are by asking for help, joining a support group, taking daily breaks, having hobbies, exercising, and seeing their own doctor (National Institute of Aging, 2017). The costs of caring for patients with cognitive illness in Florida averaged $4,000 a month in 2019 while a nursing home averages $7,500 a month (Paying for Senior Care, 2020). In St. John’s County, memory care costs an average of $4,558 a month while the national average cost of memory care is $5,361 per month (Caring, 2022). Getting in-home professional care can run on average $21 an hour and adult daycare cost approximately $1,500 a month (Paying for Senior Care, 2020). Many caregivers try to decrease these costs by caring for a loved one alone. Nationwide costs for the healthcare of Alzheimer’s patients in 2020 were $305 billion (Wong, 2020). This cost is expected to grow as high as $1 trillion dollars as the current population grows older (Wong, 2020). In 2020, the CDC estimated that there were just under six million people with Alzheimer’s (Sachs, 2021). Approximately 10% of the cases are in Florida (Sachs, 2021). Safety is the number one concern for Alzheimer’s patients. Safety for Alzheimer’s patients is as important as childproofing a home. A home needs to have hazardous items locked up, have no slippery surfaces, and should prevent access to appliances and breakables (Mayo Clinic, 2020). There are many aspects to quality of life (QOL) for patients with cognitive illnesses. Some of these areas are cognitive function, activities of daily living (ADL), time awareness, and social interactions (Alzheimer’s Association, 2020). Avenues to improve QOL SUPPORTING CAREGIVERS OF THE AGING ADULT 6 are educating caregivers, maximizing independence, implementing care plans, and coordinating care (Alzheimer’s Association, 2020). Several ethical dilemmas may arise in caring for patients with cognitive illnesses. The first dilemma is usually the decision of whether the patient is told of their diagnosis and if so, how it is to be explained (Heerema, 2021). Another may be when to have the patient give up driving (Heerema, 2021). While the patient feels this is a loss of independence, it does need to be addressed due to safety concerns (e.g., getting lost or having an accident). One issue with legal and ethical implications is when to enact a power of attorney (Heerema, 2021). There comes a time when the patient can no longer make rational decisions and someone else needs to be in charge. There are different kinds of legal issues that may arise; for example, the patient's legal capacity and legal documents. Documents that may be needed include a power of attorney, a standard will, a living trust, a living will, and a guardian/conservatorship (Alzheimer’s Association, 2022b). Purpose of the Program Evaluation Project The COA provides community services to the elders of St John’s County. The program director acts as a facilitator between community caregiving and the COA. Community businesses, organizations, and volunteers along with the COA provide funding, marketing, and referrals to community caregiving. Community caregiving falls under the ownership of the COA and is governed by its board, directors, and shareholders. The Savvy Caregiver intervention is a program of education and resources that recently became available in St. Johns County. This type of intervention does reduce the stress levels in the caregiver of individuals with cognitive illness (Savvy Caregiver, 2022). SUPPORTING CAREGIVERS OF THE AGING ADULT 7 The first SMART goal for this program evaluation was that by the end of the project (February 2023) the project manager would determine if the three programs used by the COA to decrease caregiver burden met the standards of the CDC. The second SMART goal was to improve access to programs that meet the CDC requirements for caregivers in St. John’s County, Florida by removing any programs that do not meet the CDC requirements for programs. The final SMART goal was to review the content of the three programs with the subject matter experts at the COA by February 2023. Program Problem Statement For interprofessional staff supporting caregivers of the aging adult (P), how does a formal program evaluation strategy for program selection and utilization to engage and support caregivers of the aging adult (I) compared the current structured program evaluation strategy (C) influence the efficacy of program selection for sustainability (O)?

Several ethical dilemmas may arise in caring for patients with cognitive illnesses. The first dilemma is usually the decision of whether the patient is told of their diagnosis and if so, how it is to be explained (Heerema, 2021). Another may be when to have the patient give up driving (Heerema, 2021). While the patient feels this is a loss of independence, it does need to be addressed due to safety concerns (e.g., getting lost or having an accident). One issue with legal and ethical implications is when to enact a power of attorney (Heerema, 2021). There comes a time when the patient can no longer make rational decisions and someone else needs to be in charge. There are different kinds of legal issues that may arise; for example, the patient's legal capacity and legal documents. Documents that may be needed include a power of attorney, a standard will, a living trust, a living will, and a guardian/conservatorship (Alzheimer's Association, 2022b).

Purpose of the Program Evaluation Project
The COA provides community services to the elders of St John's County. The program director acts as a facilitator between community caregiving and the COA. Community businesses, organizations, and volunteers along with the COA provide funding, marketing, and referrals to community caregiving. Community caregiving falls under the ownership of the COA and is governed by its board, directors, and shareholders. The Savvy Caregiver intervention is a program of education and resources that recently became available in St. Johns County. This type of intervention does reduce the stress levels in the caregiver of individuals with cognitive illness (Savvy Caregiver, 2022). SUPPORTING CAREGIVERS OF THE AGING ADULT 7 The first SMART goal for this program evaluation was that by the end of the project (February 2023) the project manager would determine if the three programs used by the COA to decrease caregiver burden met the standards of the CDC. The second SMART goal was to improve access to programs that meet the CDC requirements for caregivers in St. John's County, Florida by removing any programs that do not meet the CDC requirements for programs. The final SMART goal was to review the content of the three programs with the subject matter experts at the COA by February 2023.

Program Problem Statement
For interprofessional staff supporting caregivers of the aging adult (P), how does a formal program evaluation strategy for program selection and utilization to engage and support caregivers of the aging adult (I) compared the current structured program evaluation strategy (C) influence the efficacy of program selection for sustainability (O)?

Population
The population for this intervention was individuals who care for patients with cognitive illnesses, such as Alzheimer's or dementia. The age of the caregivers can vary based on the capacity of the individual caregiver. Caregivers needed to be able to understand and speak English or have someone who can assist. The caregiver was a family member, close friend, or volunteer.

Intervention
One caregiver program is titled "Savvy Caregiver" and is an EBP education program offered by the COA in St. John's County. The Savvy Caregiver program was new at the COA in St. John's County and has been offered since August 2022. Currently, the program that the COA offers is a digital class consisting of three modules that provides some education and information on resources available to caregivers. These modules were created by the head nurse at the COA and are sent to caregivers once they are referred to the COA. The three modules cover some medical aspects of a cognitive illness and changes that may occur in the patient over the span of their illness. Caregiver resources are shared and contact information for different programs is listed.
The Savvy Caregiver has an established timeline and was developed at the University of Minnesota and originally published in 2002. The intervention may be conducted in person, as a hybrid course, or virtually. The program was originally developed as a six-week class with weekly meetings lasting two hours each. This timeline can be adjusted based on the needs of the user. There is online training for those wishing to teach the program. This training will be completed by the Project Manager and staff at the COA. The costs ($1,499) associated with the Savvy Caregiver program include training for the individuals teaching the class and resources for the participants. The rights to the Savvy Caregiver program are held by the University of Minnesota.
The second program was the Powerful Tools for Caregivers. This program can also be offered in virtual or in-person sessions. Powerful Tools provides caregivers with the caregiver help book. This book provides tools that are designed to reduce stress, improve self-confidence, manage time/set goals/solve problems, communicate their feelings, make difficult decisions, and locate resources (this book is available in English and Spanish). Research has shown that this program has increased self-care behaviors, decreased depression, increased confidence, and increased the use of community resources among caregivers of individuals with cognitive illnesses (Alzheimer's Association, 2022c).
The third program is an original program designed by the community caregiving manager at the COA. It was developed to help meet the need of caregivers who felt unprepared after receiving a diagnosis of cognitive illness for a loved one. It consists of three modules that have been recorded so it can be presented in person or online. The modules contain information on the disease process of cognitive illness, symptoms that may be encountered, how best to work with individuals with cognitive illness, and caregiver resources for help.

Comparison
The comparison was evaluating the three programs currently in use at the COA against the framework of the requirements of the CDC for successful programs.

Utility of Program Review
The site for this program evaluation was located in St. Johns County, Florida. The facility is a private not-for-profit that provides social support and assistive services for caregivers of individuals with cognitive illnesses. The facility uses "Community Caregiving" which is a social model of a memory disorder clinic. The services provided were supervised by a qualified dementia care specialist. The mission was to promote an environment of optimization and function for elders in St. John's County. The vision statement was "We will lead the emphasis on addressing the social needs of chronic illness to promote optimal aging programs and advocate for reversal of stigma for aging elders shifting their experience into one of empowerment and engagement in both civic and personal endeavor" (COA Business Plan, 2021, p. 1).
The stakeholders included the program director, the chief financial officer, the patients, their caregivers, and the doctorate of nursing practice (DNP) student from the University of St.
Augustine for Health Sciences (USAHS) acting as the project manager for this EBP. An additional stakeholder is the COA. Organizational support was obtained through the development of a business plan which was presented to the COA and accepted. The business plan identified the location of a community caregiving office within the Flagler Hospital office complex which was under the direction of the director of caregiver support at the COA.
Community caregiving development and implementation of services will be an enhancement to the quality of care and services provided to the elderly and their caregivers in St. Johns County.
The memory disorder clinic is a subsidiary of the COA.
Completion of this evaluation provided data that allowed the COA to determine that all three programs can continue to be used. With this knowledge, the COA was able to adapt and adjust the offerings to best meet the needs of caregivers. This information was shared with other agencies, which can lead to more programs that are tailored to best decrease caregiver burden.

Analytical Framework
The Centers for Disease Control (CDC) Program Evaluation Framework (PEF; CDC, 1999) was used to guide this program evaluation. The framework consists of six steps: engage stakeholders, describe the program, focus the evaluation design, gather data, justify conclusions, and share lessons learned (CDC, 1999). The project was designed by presenting data showing that evidence-based practice (EBP) programs can decrease caregiver burden in caregivers of individuals with cognitive illnesses.
For the first step of the framework, the stakeholders were engaged in the process and approved the implementation of the evaluation of the three programs used by the COA (Savvy Caregiver, original modules, and Powerful Tools for Caregivers). For the second step, the need for programs to decrease caregiver burden was assessed. The three programs were looked at as activities that could be used to reach the goal of decreasing caregiver burden. The costs of implementing each program were reviewed, and a logic model was developed with the stakeholders looking at inputs, activities, outputs, and outcomes. Each of the three programs was compared using the logic model. For the third step in the framework, the purpose of the evaluation was addressed (determining if the three programs currently in use decrease caregiver burden); in addition, the user population was determined as well as how the information was to be supplied and what procedures would help reach the determination if the programs decreased caregiver burden.
Step four involved the collection of evidence and the development of data metrics that could be tabulated and reports run in AIMSPlus. The AIMSPlus application is a client information management system that enables home and community-based service providers to accurately and efficiently track client/caregiver demographic information; care plans and case notes, home and facility-provided services, transportation routes, meal schedules, agency service costs, and analysis, and perform electronic service billing and reporting. A Google form as well as individually entered demographic and education data was used to gather the data for the metrics. The information was provided directly by the caregiver. The reports were run weekly.
To justify the conclusions, the stakeholders would like to see a decrease in caregiver burden to see if the programs are successful. A decrease in caregiver burden leads to better health for both the caregiver and the individual for whom they are caring. There is also a cost saving to both the caregiver and the state based upon costs previously discussed for the care of individuals with cognitive illness.
To ensure the use and sharing of lessons, the program evaluation was designed for use by the facility to meet their specific needs. Steps were taken to share the evaluation process (CDC PEF, 1999) with stakeholders so that they could continue to evaluate programs in the future.
Feedback was shared among the stakeholders to ensure the communication was trustworthy.
Follow-up was done by the program director and her staff to ensure the reports were reviewed monthly to see if the programs had continued success and to evaluate new programs as they were implemented. The lessons learned were disseminated by a presentation of a PowerPoint and the provision of copies of this program evaluation.

Evidence Search Strategy, Results, and Evaluation
Using the CDC framework (1999) provides a place to start or a plan to work from to measure outcomes, but the program evaluation must be supported with evidence from current literature. While EBP is known to have positive results, it is necessary to have data from each program to determine that the program meets the minimum standards (CDC, 1999)

Search Strategy
The literature search was completed using resources from the USAHS Library. All databases were searched from 2017-2022 in English using the MeSH search terms (caregivers of cognitive illness) AND (Savvy Caregiver)(Powerful tools for caregivers) AND (decrease caregiver burden). Searches in all databases were also searched after removing the search terms (caregivers of cognitive illness) to obtain more results. Articles were limited to English text, systematic reviews, and scholarly journals within the last five years. The search terms were taken from the PICO question. Results of the database searches were: CINAHL one article found, Search USA 40 articles found (additional search perimeter of peer-reviewed and academic journal), OVID one article found, Pub Med two results found. Duplicate articles from the four databases were excluded. The abstracts were reviewed, and only the articles with relevant information to the evidence-based project were reviewed in full. Duplicate articles from the five databases were excluded. Articles older than five years and that did not contain relevant information were excluded.

Results
The initial search used the MeSH search terms (caregivers of cognitive illness) AND (Powerful tools for caregivers) AND (decrease caregiver burden). The first run of the search terms in Search USA came up with 40 articles. The search was further narrowed by adding peer review and 2017-2022 (publication dates) as a requirement and individually searching CINAHL, OVID, and PubMed. This further search turned up four additional articles that were reviewed in full. Duplicate articles were excluded bringing the total number of articles to 27. After reviewing the 27 articles those with no relevance to the focus of this project were also excluded leaving ten articles.
An additional search was completed using MeSH terms (Savvy Caregiver Program). The

Evaluation
The articles were reviewed using the Johns Hopkins Evidence Level and Quality Guide (Dang & Dearholt, 2017) for evidence and quality. Based upon the John Hopkins model, there was three Level I studies, two Level II studies, three Level III studies, 0 Level IV studies, and three Level V studies. The quality of the studies was 10 A, one B, and 0 C (Dang & Dearholt, 2017). See Table 1 for a display of evidence and the quality of articles included.

Critical Appraisal of the Evidence with Themes
Table 1 discussed the themes found in the eleven articles that were reviewed in full. Of the three themes identified after reviewing the literature, there were direct comparisons to the population (caregivers of individuals with cognitive illness), intervention (a caregiver education program), and outcome (decrease in caregiver stress/burden).

Caregiver Identification
Several of the articles utilized caregivers of individuals with cognitive illnesses (Evans et al., 2020;Lin et al., 2018;Miller et al., 2020;Paul et al., 2019;Quinn et al., 2020;Sztramko et al., 2021). This is the population previously identified for this project. The cognitive illnesses were determined in different ways, such as a mini-mental status exam (MMSE) or a diagnosis of Alzheimer's disease at any stage (Paul et al., 2019, Evans et al., 2020. Caregivers were also classified as friends or family members (non-paid was not mentioned but implied). Some of the literature also incorporated an evaluation of caregivers of individuals with other diseases as well as cognitive illnesses.

Caregiver Education Programs
Another theme that appeared in the literature was the development and/or implementation of a caregiver education program (Paul et al., 2019, Evans et al., 2020, Sztramko et al., 2021. Some of the programs were in person while some were online training (Paul et al., 2019, Evans et al., 2020, Sztramko et al., 2021. Changes in caregivers' perception of burden or stress were evaluated before and after caregiver participation in an education program (Paul et al., 2019, Evans et al., 2020, Sztramko et al., 2021. A Native American elder caregiver education program was successful in allowing caregivers to learn strategies for coping with repetitiveness and confusion, such as distraction, reminiscence, and refraining from testing memory The PTC was evaluated using the 22-item ZBI (Terracciano et al., 2020). Using an unidentified pre/post-test Gerdner (2011) found that there was a decrease in caregiver burden after attending the PTC program.

Assessing Caregiver Burden
Several of the articles had similar themes of assessing caregiver burden pre and posteducational intervention with questionnaires (Lin et al., 2018, Quinn et al., 2020, Paul et al., 2019, Miller, Killiam, & Fields, 2020, Sztramko et al., 2021. If the caregiver's perceptions of burdens are the result of the efforts of caregiving, then it is probable that having fewer restrictions, secondary to receiving more assistance and knowledge with caregiving education programs, would reduce caregivers' burden levels (Lin et al., 2018, Quinn et al., 2020, Paul et al., 2019, Miller, Killiam, & Fields, 2020, Sztramko et al., 2021. These findings indicate that caregiver education programs decrease caregivers' perceptions of burdens/stress (Lin et al., 2018, Quinn et al., 2020, Paul et al., 2019, Miller, Killiam, & Fields, 2020, Sztramko et al., 2021. There is some evidence that online interventions improve caregiver-related outcomes such as self-efficacy, depression, dementia knowledge, and quality of life; and decrease caregiver burden (Sztramko, et al., 2021). A study of American Indians with cognitive illness and their caregivers found that caregivers described low levels of burden and high levels of reward in being able to care for their family members while maintaining their cultural beliefs (Dunn, Schwartz, Teufel-Shone, & Meyer, 2019).

Evidence-based Recommendation Statement
Practice recommendations from the literature indicated that EBP programs (specifically Savvy Caregiver and Powerful Tools for Caregivers) can decrease the burden felt by caregivers caring for individuals diagnosed with cognitive illnesses. The literature synthesis (Appendix B) demonstrated that the evaluated caregiver programs that use evidence-based practice education programs do decrease caregiver burden. After completing this literature review, the recommendation was that all caregiver programs should be evaluated following the CDC's PEF to provide guidance to staff in deciding which programs to implement. Once the results of the PEF were tabulated, the project manager was able to determine that all three programs should be continued as they all met the CDC requirements.

Program Analysis and Evaluation Plan
The project manager reviewed the CDC PEF (1999) in order to determine the development of a toolkit for caregiver programs. The six steps of the CEC framework were used to evaluate the three programs currently used in St. John's County.

Engage Stakeholders
The staff who conducted the evaluation of the caregivers were used for the evaluation.
The project manager researched the population of caregivers of individuals with cognitive illness to better understand the population the staff would be interacting with. Spending time with the staff enabled the project manager to determine the stakeholder's feelings on the objectives and outcomes to be evaluated.

Describe the Program
To best determine the different sections of the program to be evaluated, the inputs, outputs, and moderators were identified (CDC, 2017). After identifying what the different programs do to enable change, the project manager developed a logic model (Figure 7) to show a clear link between the programs and the outcomes.

Focusing the Evaluation Design
The program evaluation and toolkit were developed to help the staff determine which programs best meet their goal of decreasing caregiver burden. This step of the evaluation used SMART goals to ensure that the important aspects were being addressed.

Gather Credible Evidence
There were five elements considered in this step: indicators, sources of evidence, quality, quantity, and logistics (CDC, 2012). In order to find the best evidence, the program manager searched for research that had been conducted on the two national programs and communitylevel evaluation of the original three-module program from the COA.

Justify Conclusions
The evaluation and synthesis of the programs were used to determine if there were patterns and if these patterns influenced the effectiveness of the programs (CDC, 2017).
Common themes were identified among the programs. These themes allowed a better understanding of the performance of the programs. The project manager used the results to determine if the performance of the program met the CDC standards and then decided on the recommendations to make. Based on the CDC model, it was determined if each program should be continued.

Ensure Use and Share Lessons Learned
The project manager worked to determine knowledge about the programs that could be generalized with the goal of sharing this knowledge (CDC, 2017). The evaluation design was determined during the project proposal process. The findings of the program analysis were used to develop a toolkit for caregiver programs in St. John's County. A dissemination plan was developed in order to share the lessons learned with the stakeholders of the project.

Program Evaluation Discussion and Recommendations
Program evaluation of caregiver support programs was conducted using the CDC's Program Evaluation Framework to analyze the content of the three programs currently in use by St. John's County: Savvy Caregiver, Powerful Tools for Caregivers, and the COA's three model program. These programs were chosen for their focus on caregivers of individuals with cognitive illness and their goal of decreasing caregiver burden.
The program evaluation looked at the three programs using the six identified CDC categories along with the prescribed standards for each of the six categories (CDC, 1999). The project manager identified themes among the three programs that related to the program description, credibility, design, standards to justify conclusions, stakeholder values, and dissemination avenues. Each of the six categories was further divided into steps (the number of steps varied based on which category was being completed).
Each program was reviewed and determined to exceed expectations, meet expectations, or not meet expectations. This determination was then assigned a number so that descriptive statistics could be analyzed, 0=not meet, 1=meet, 2=exceeds. The descriptive statistical mean value of greater than or equal to 1 indicated program consistently met the standards as related to the six identified categories of the CDC framework. The findings for Savvy Caregiver averaged 1, Powerful Tools for Caregivers averaged 1, and the COA modules averaged 0.95. See Table 2 for details. This evaluation determined that the Savvy Caregiver and Powerful Tools for Caregivers had the same score, so these programs are presented in the data sets as a single program. The evidence was statistically analyzed using Intellecctus Statistical software (2022). A repeated measures analysis of variance (ANOVA) with one within-subjets factor was conducted to determine whether significant differences exist between Savvy Caregiver/Powerful Tools for Caregivers and the COA modules. See Tables 3 and 4  The programs were reviewed to determine their relevance to the evidence found in the literature synthesis. Themes were identified and supporting evidence was determined. The three programs were analyzed to determine the currency of literature and its relevance to the caregiver population. This analysis was completed by reviewing the three programs against the evidence by assigning them a value of present and current (PC), present and needs updating (PU), and missing current evidence (M). See Table 5 for details.
The objectives of this project were to identify and evaluate three caregiver programs, analyze the content to determine recommendations for practice and develop a toolkit for evaluating caregiver programs. The evaluation results indicated that the three programs meet the requirements of a program per the CDC Program Evaluation Framework. The evidence also supported the current use of these three caregiver programs. The evaluation also concluded that the Savvy Caregiver and Powerful Tools for Caregivers are the more complete programs for use in caregiver education.
A limitation of this program evaluation was that it was completed using public, published content for the available programs. Subject matter experts were consulted during the development of the caregiver program evaluation toolkit. See Appendix C for the toolkit.

Dissemination
The project was presented via Zoom using a PowerPoint presentation and will be available for USASHS students and faculty as well as the COA staff. The findings were presented to the COA in paper copy and digital versions. At this time, there are no plans for the presentation of the findings at the regional or national meetings. Publication may be pursued in the future. The leading journal for Alzheimer's and dementia is Alzheimer's & Dementia: The Journal of the Alzheimer's Association; it is also a peer-reviewed journal. These qualities make these two journals a good selection for publication. This manuscript was also uploaded into SOAR, which is part of the St. Augustine School of Health Sciences' online presence.

Conclusion
This project evaluated the ability of the EBP programs Savvy Caregiver, Powerful Tools for Caregivers, and the COA's original three modules to determine if they met the criteria of the CDC for successful programs. Caregiver burden is a real issue, so having successful programs in place is essential. When caregivers feel an increased burden, it can lead to poor outcomes for the individuals they care for as well as the caregiver. After completing the evaluation framework provided by the CDC (1999), it was determined that all three programs currently in use meet the CDC's criteria. They will continue to be utilized to help prepare caregivers for challenges they may face and to provide them with resources to help decrease caregiver burden. Any programs that will be considered in the future will be evaluated using the toolkit developed for this program evaluation before they are implemented to ensure that they also meet the CDC criteria before being https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4496054/     Table 4 Means   Barplot of COA_Modules_Nominal_Nominal

Figure 7
Logic Model The review of existing mental health and other caregiver questionnaires to determine whether they address four key domains related to caregiving work demands, resource needs, resource utilization, and costs. This assessment is useful in that different areas of the impact of caregiving can be better described and contribute to a more informed discussion about developing meaningful and effective policies and programs. The caregivers that participated in the education program showed a decrease in stress.
The correlation of decreasing stress with an education program agrees with the premise of this evidence-based project of developing an educational program for caregivers.

POSITION STATEMENT:
Screening for the need of caregiver programs should be reviewed and updated at least annually to ensure optimal health outcomes for caregivers and their patients.

POLICY STATEMENT:
Clinic staff should ensure that up-to-date screening of caregiver programs takes place and is filled annually. The program director should review the results, determine if the caregiver has need of a program, refer the caregiver per clinic policy, and follow up to see if needs have been met.