Coordinated Care Management For Dementia In A Large Academic Health System

Abstract

Alzheimer’s disease and other dementias are chronic, incurable diseases that require coordinated care that addresses the medical, behavioral, and social aspects of the disease. With funding from the Center for Medicare and Medicaid Innovation (the Innovation Center), we launched a dementia care program in which a nurse practitioner acting as a dementia care manager worked with primary care physicians to develop and implement a dementia care plan that offers training and support to caregivers, manages care transitions, and facilitates access to community-based services. Post-visit surveys showed high levels of caregiver satisfaction. As program enrollment grows, outcomes will be tracked based on the triple aim developed by the Institute for Healthcare Improvement and adopted by the Centers for Medicare and Medicaid Services: better care, better health, and lower cost and utilization. The program, if successful at achieving the triple aim, may serve as a national model for how dementia and other chronic diseases can be managed in partnership with primary care practices. The program may also inform policy and reimbursement decisions for the recently released transitional care management codes and the complex chronic care management codes to be released by Medicare in 2015.

Impact of an Intensive Dementia Caregiver Training Model on Knowledge and Self‐Competence: The Improving Caregiving for Dementia Program

“…The University of California Los Angeles (UCLA) Alzheimer's and Dementia Care Program (ADCP) is a dementia care comanagement program whose interventions and outcomes have previously been described . We developed the UCLA Improving Caregiving for Dementia (I‐CareD) Caregiver Bootcamp, an intensive, community‐based, 1‐day training for caregivers enrolled in the ADCP.…”

Patient and caregiver goals for dementia care

“…Participants were recruited from the UCLA health system and the UCLA Alzheimer’s and Dementia Care (ADC) Program, a comprehensive dementia care management program, 20, 21 and five community-based organizations that provide dementia-related services in partnership with the UCLA ADC Program. Participants were recruited using flyers posted in clinical areas and at community-based organizations, and mailers were sent to people who indicated interest in receiving information about research studies.…”

2020 Alzheimer's disease facts and figures

“…Other models include addressing the needs of family caregivers simultaneously with comprehensive disease management of people living with dementia to improve the quality of life of both 498 . Several evaluations have suggested that such approaches have considerable potential for improving outcomes for people with dementia and their family caregivers (for example, delayed nursing home admission and reduction in caregiver distress) 499‐508 . Current research is attempting to determine the feasibility of these models beyond the specialty settings in which they currently operate 509‐512 …”