Implementation and Review of the Care Ecosystem in an Integrated Healthcare System

Abstract

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.

2024 Alzheimer's disease facts and figures

“…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 postenrollment and by $3,027 from 7 to 12 months post-enrollment, corresponding to a mean monthly cost reduction of $526 across 12 months. 757 An implementation toolkit for the Care Ecosystem is publicly available at: https://memory.ucsf.edu/sites/memory.ucsf.edu/files/ wysiwyg/CareEcosystemToolkit.pdf.…”

“…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 757 .…”