Background and Objectives The University of California, San Francisco Memory and Aging Center (UCSF-MAC) led the development and tested a collaborative care model delivered by lay care team navigators (CTNs) with support from a multidisciplinary team known as the Care Ecosystem (CE). We report the results from the application of the CE within a non-academic healthcare system. Research Design and Methods The CE team at HealthPartners consisted of two CTNs, a social worker, an RN, a program coordinator, and a behavioral neurologist. Intake forms were developed to collect demographic, baseline, and annual longitudinal data at one year related to dementia severity and care partner status. Experience surveys were completed every 6 months by participating care partners. All data was entered into REDCap. Results A total of 570 PWD-caregiver dyads were recruited into the CE: 53% PWDs female, average age 75.2 ± 9.43, 19% living within rural communities. Of the 173 dyads assessed at one year, 58% of care partners responded to surveys, and 67% of those provided data about their CE experience through survey data. At one year, PWDs progressed in disease severity and functional impairment, although care partner burden and mood remained unchanged. We observed a significant reduction in care partner reported emotional challenges associated with caregiving, sleep problems, and obtaining care partner help at one year. Eighty-six percent of care partners reported feeling supported by their CTN nearly always or quite frequently, and 88% rated the CTN as highly responsive to what was important to them. Discussion and Implications The CE was feasible and well-received within a non-academic healthcare system.
Background:The Care Ecosystem (CE) is a model of dementia care consisting of a multidisciplinary team of nursing, care team navigators (CTNs), and social workers designed to support persons with dementia (PWD) and their caregivers. Developed and tested at the UCSF Memory and Aging Center, the CE has been shown to improve PWD quality of life, reduce emergency department visits, and decrease caregiver depression/burden compared to usual care. We present CE data from a high volume neurology clinic within an integrated healthcare system.Method: A total of 435 patient-caregiver dyads were enrolled in the CE over a 2.5 year period. Data relating to demographics, dementia severity, caregiver burden, and healthcare utilization were collected at baseline and after one year (n=116). Experience surveys were completed by dyads at 6 and 12 months (n=200). A retrospective review of data captured by RedCap and the electronic medical record was performed.Result: There was worsening of dementia disease severity (DSRS) and functional impairment (FAQ) over a one year period (figure 1a/b). Both immediate/anticipated caregiver needs (figure 2) and safety concerns (figure 3) decreased over time. For safety, there were particular sizable reduction of caregiver safety concerns for driving (65%), falls (52%), problems getting lost (57%), weight and appetite changes (63%), and medication safety concern (61%) for the PWD. There was a reduction in the number of PWD using >10 medications with the CE (figure 4). The number of ED visits decreased over time whereas hospitalizations increased over the one year (figure 5a/5b). There was a reduction in caregiver depression, difficulty, and burden (6a/b/c). Dyads rated CTNs favorably ranging from 88-92% of the time. Conclusion:Our results suggest that the CE is feasible and effective in an integrated healthcare system setting. Despite worsening of disease state in the PWD, caregiver burden and distress decreased over the one year assessment period, suggesting a favorable impact on caregiver quality of life. PWD and caregivers rated the CTN experience positively. Although these preliminary results favor the CE, further studies are necessary to better understand the impact of the CE on healthcare utilization in integrated healthcare systems.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.