Quality of Care Provided by a Comprehensive Dementia Care Comanagement Program

Abstract

Multiple studies have shown that quality of care for dementia in primary care is poor with physician adherence to dementia quality indicators (QIs) ranging from 18-42%. In response, the University of California, Los Angeles Health System created the UCLA Alzheimer’s and Dementia Care (ADC) Program, a quality improvement program that uses a co-management model with a nurse practitioner dementia care manager (DCM) working with primary care physicians and community-based organizations to provide comprehensive dementia care. Our objective was to measure the quality of dementia care provided by nurse practitioner DCMs using the Assessing Care of Vulnerable Elders (ACOVE-3) and Physician Consortium for Performance Improvement QIs. Participants included 797 community-dwelling adults with dementia referred to the UCLA ADC program over a two-year period. UCLA is an urban academic medical center with primarily fee-for-service reimbursement. We measured the percentage of recommended care received for 17 dementia QIs. The primary outcome was aggregate quality of care for the UCLA ADC cohort calculated as the total number of recommended care processes received divided by the total number of eligible quality indicators. Secondary outcomes included aggregate quality of care in three domains of dementia care: assessment and screening (7 QIs), treatment (6 QIs), and counseling (4 QIs). QIs were abstracted from DCM notes over a three-month period from date of initial assessment. Patients were eligible for 9,895 QIs, of which 92% were passed. Overall pass-rates among DCMs were similar (range 90% to 96%). All counseling and assessment QIs had pass-rates >80% with most exceeding 90%. Wider variation in adherence was found among QIs addressing treatments for dementia, which were triggered by patient-specific criteria, ranging from 27% for discontinuation of medications associated with mental status changes to 86% for discussion about acetylcholinesterase inhibitors. Comprehensive dementia care co-management with a nurse practitioner can result in very high quality of care for dementia, especially for assessment, screening and counseling. The effect on treatment QIs is more variable but higher than previous reports of physician-provided dementia care.

Clinicians' Perspectives on Barriers and Enablers of Optimal Prescribing in Patients with Dementia and Coexisting Conditions

“…Nonpharmacologic interventions, such as structured activities, caregiver training, and comanagement with nonphysician care managers, have been shown to improve problem behaviors, reduce caregiver burden, improve patient and caregiver quality of life, or delay institutionalization. [33][34][35][36] Yet, clinicians said that access to such services is poor. This may explain why education and support for nonpharmacologic strategies often take the form of a pamphlet from the clinician or the location of a support group.…”

The Effect of a Comprehensive Dementia Care Management Program on End‐of‐Life Care

“…Comprehensive dementia disease management programs have also been developed to address poor quality of care in dementia, including low rates of advance care planning and low use of palliative care and hospice services . The University of California, Los Angeles (UCLA), Alzheimer's and Dementia Care (ADC) program, a longitudinal, comprehensive nurse practitioner dementia comanagement program, was launched in November 2011 and has resulted in high quality of care, with pass rates exceeding 90% on advance care planning process‐of‐care measures …”

Patient and Caregiver Benefit From a Comprehensive Dementia Care Program: 1‐Year Results From the UCLA Alzheimer's and Dementia Care Program

“…4 Increasingly, clinical programs are being evaluated on their ability to meet the triple aim of better care, better health, and lower costs. 8 We have previously reported the effect of the UCLA ADC Program on the quality of dementia care 9 and Medicare costs. 10 In this article, we report 1-year patient and caregiver clinical outcomes and predictors of clinical benefit of the program.…”