Tailored Caregiver Assessment and Referral Support System (TCARE)

Primary Practice

Assessment and referral support system


Tailored Caregiver Assessment and Referral (TCARE) is a care management protocol designed to support family members who are providing care to adults, of any age, with chronic or acute health conditions. It was designed to help care managers efficiently triage resources and services available within a community to effectively address the caregivers’ needs. The comprehensive system includes software, assessment tools, decision algorithms, and a training and technical assistance program. TCARE is grounded in the Caregiver Identity Theory, which conceptualizes caregiving as a series of transitions that result from changes in the caregiving context and in personal norms that are grounded in familial roles and culture.

TCARE is implemented by a care manager who is certified as a TCARE assessor. The care manager uses a web based software to conduct an interview with the caregiver to obtain information including demographics, length and phase of caregiving, obligations, and physical and emotional health. The care manager also collects information related to the person with disabilities such as demographics and activities of daily living. A final score is given after the assessment (interviews), which the care manger uses in order to identify intervention goals, strategies, and an initial list of recommended services and resources (e.g., respite services, psychoeducational skills training, cognitive behavioral therapy, family counseling) from a catalog of 90 types of services.

These recommendations, including the type of services and the amount of services, are tailored to the caregiver’s needs, preferences, and availability. The care manager consults with the caregiver to discuss the findings and provides the caregiver with information to make an informed choice on whether to use the recommended services and how the services will help with his or her caregiving needs. The process is repeated at 3-month intervals for the care plan to be adjusted as appropriate. The full assessment and referral process require 2½ to 3 hours of staff time to complete.

Target Population(s)

Caregivers of older adults


Has been implemented in states, including Washington State’s Family Caregiver Support Program. Washington State Department of Social and Health Services; Aging and Adult Care: Area Agency on Aging


Process to assess caregiver needs and link with appropriate services and supports.

Evidence of Outcomes

Evidence-Based Practice
A longitudinal, randomized, and controlled intervention study with 266 family caregivers served by 52 care managers in 4 states was conducted using repeated measures random effects regression procedures (Montgomery, Kwak, Kosloski, & O’Connell, 2011). Caregivers in the intervention and control groups were repeatedly assessed for up to 9 months on caregiver identity discrepancy, 3 areas of caregiving burden—objective, relationship, and stress burdens; depression; and intention for nursing home placement. There were significant group by time interaction effects for caregiver identity discrepancy, relationship burden, stress burden, depression, and intention for nursing home placement. Caregivers in the intervention group experienced significant improvement on these measures, whereas caregivers in the control group worsened on these measures over time.

Kwak, Montgomery, Kosloski, & Lang (2011) conducted a longitudinal, randomized controlled trial with 97 caregivers enrolled in a demonstration project in Georgia. A greater variety of services were recommended to and used by caregivers in the intervention group than in the control group. Caregivers in the intervention group had lower caregiver identity discrepancy, stress burden, and depressive symptoms over time than caregivers in the control group.

Additional Information

TCARE Website: http://tailoredcare.com/


Kwak, J., Montgomery, R.J.V., Kosloski, K., & Lang, J. (2011). The Impact of TCARE® on service recommendation, use, and caregiver well-being. The Gerontologist, 51(5), 704–713.

Montgomery, R.J.V., Kwak, J., Kosloski, K., & O’Connell Valuch, K. (2011). Effects of the TCARE® intervention on caregiver burden and depressive symptoms: preliminary findings from a randomized controlled study. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 66(5), 640–647.

Montgomery, R.J.V. (May, 2014). Has the use of Tailored Caregiver Assessment and Referral® System Impacted the Well-being of Caregivers in Washington? Report to the Washington Aging and Long-Term Support Administration. Helen Bader School of Social Welfare University of Wisconsin-Milwaukee.