Care Ecosystem Collaborative Model and Health Care Costs in Medicare Beneficiaries With Dementia

Abstract

ImportanceCollaborative dementia care programs are effective in addressing the needs of patients with dementia and their caregivers. However, attempts to consider effects on health care spending have been limited, leaving a critical gap in the conversation around value-based dementia care.ObjectiveTo determine the effect of participation in collaborative dementia care on total Medicare reimbursement costs compared with usual care.Design, Setting, and ParticipantsThis was a prespecified secondary analysis of the Care Ecosystem trial, a 12-month, single-blind, parallel-group randomized clinical trial conducted from March 2015 to March 2018 at 2 academic medical centers in California and Nebraska. Participants were patients with dementia who were living in the community, aged 45 years or older, and had a primary caregiver and Medicare fee-for-service coverage for the duration of the trial.InterventionTelehealth dementia care program that entailed assignment to an unlicensed dementia care guide who provided caregiver support, standardized education, and connection to licensed dementia care specialists.Main Outcomes and MeasuresPrimary outcome was the sum of all Medicare claim payments during study enrollment, excluding Part D (drugs).ResultsOf the 780 patients in the Care Ecosystem trial, 460 (59.0%) were eligible for and included in this analysis. Patients had a median (IQR) age of 78 (72-84) years, and 256 (55.7%) identified as female. Participation in collaborative dementia care reduced the total cost of care by $3290 from 1 to 6 months postenrollment (95% CI, −$6149 to −$431; P = .02) and by $3027 from 7 to 12 months postenrollment (95% CI, −$5899 to −$154; P = .04), corresponding overall to a mean monthly cost reduction of $526 across 12 months. An evaluation of baseline predictors of greater cost reduction identified trends for recent emergency department visit (−$5944; 95% CI, −$10 336 to −$1553; interaction P = .07) and caregiver depression (−$6556; 95% CI, −$11 059 to −$2052; interaction P = .05).Conclusions and RelevanceIn this secondary analysis of a randomized clinical trial among Medicare beneficiaries with dementia, the Care Ecosystem model was associated with lower total cost of care compared with usual care. Collaborative dementia care programs are a cost-effective, high-value model for dementia care.Trial RegistrationClinicalTrials.gov Identifier: NCT02213458

Transforming Value-Based Dementia Care—Implications for the GUIDE Model

“…GUIDE seeks to alleviate caregiver burden by providing unpaid caregivers with training, access to a 24/7 support line, and reimbursement of up to $2500 annually for respite services. This builds on previous evaluations of effective interventions to improve caregiver well-being …”

“…The traditional, disease-based approach fails patients with dementia because of fragmented care and inadequate consideration of both the patient-caregiver unit and the social needs of patients. In contrast, comprehensive dementia care models use individualized care plans and prioritize longitudinal, team-based follow-up to achieve utilization-driven reductions in spending on beneficiaries with dementia . However, with substantial upfront fixed costs, these models are not tenable under the incentives of FFS.…”

“…Site-of-care selection may also be a feasible vehicle for savings under GUIDE, given that comprehensive dementia care programs have been shown to delay admission to long-term care facilities. However, care coordination for dementia has not consistently produced a meaningful reduction in emergency department use or inpatient admissions . Available savings from utilization changes alone may vary based on disease severity and population characteristics.…”

“…Dementia disproportionately affects older adults and represents an increasingly difficult population health and financial challenge for Medicare. Annual spending for Medicare beneficiaries with dementia is approximately 3 times higher than that for patients without dementia, with excess costs attributable to substantial fragmentation across the care journey . Patients with dementia experience polypharmacy and frequent hospitalizations and require careful coordination across multiple specialty health care professionals with support from unpaid caregivers.…”

2024 Alzheimer's disease facts and figures

“…As a second example, the Care Ecosystem — a collaborative, team‐based dementia care program utilizing telehealth that involved care navigators, advanced practice nurses, social workers and pharmacists — resulted in fewer ambulance rides, emergency department visits and hospitalizations and lower total cost of care compared with usual care. 756 , 757 A non‐academic health care delivery organization which adopted the Care Ecosystem found that the model can be successfully implemented and integrated into purely clinical settings. 758 With regard to cost savings, participation in the Care Ecosystem reduced the total cost of care by $3,290 from 1 to 6 months post‐enrollment and by $3,027 from 7 to 12 months post‐enrollment, corresponding to a mean monthly cost reduction of $526 across 12 months.…”