The University of California at Los Angeles Alzheimer's and Dementia Care Program for Comprehensive, Coordinated, Patient‐Centered Care: Preliminary Data

Abstract

Dementia is a chronic disease that requires both medical and social services to provide high quality of care and prevent complications. As a result of time constraints in practice, lack of systems-based approaches, and poor integration of community-based organizations (CBOs), the quality of care for dementia is poor compared to other diseases that affect older persons. The UCLA Alzheimer’s and Dementia Care (UCLA ADC) program partners with CBOs to provide comprehensive, coordinated, patient-centered care for patients with Alzheimer’s disease and other dementias. The goals of the program are to maximize patient function, independence and dignity, minimize caregiver strain and burnout and reduce unnecessary costs. The UCLA ADC program consists of five key components: patient recruitment and a dementia registry, structured needs assessments of patients in the registry and their caregivers, creation and implementation of individualized dementia care plans based on needs assessments and input from the primary care physicians, monitoring and revising care plans, as needed, and access 24/7, 365 days a year for assistance and advice. The program uses a co-management model with a nurse practitioner Dementia Care Manager working with primary care physicians and CBOs. Based on the first 150 patients served, the most common recommendations in the initial care plans were referrals to support groups (73%), Alzheimer’s Association Safe Return (73%), caregiver training (45%), and medication adjustment (41%). The program will be evaluated on its ability to achieve the triple aim of better care for individuals, better health for populations, and lower costs.

Transitions in Care in a Nationally Representative Sample of Older Americans with Dementia

“…Recognizing the expensive inefficiencies in the current system, the Federal Government is investing significant resources in testing models of care designed to improve transitions and reduce unnecessary hospitalizations of older adults, particularly among those with dementia. 1, 30 This is necessary work to improve support at home and in nursing homes, especially as we prepare for growing numbers of patients with dementia transitioning across settings with increasing levels of acute and chronic care needs.…”

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.…”

Coordinated Care Management For Dementia In A Large Academic Health System

“…The UCLA ADC (12) program seeks to improve dementia care by addressing three important gaps in dementia care: lack of support and training for caregivers, poor care transitions, and inconsistent access to community-based services. It began in November 2011 with support from philanthropic organizations and the UCLA health system.…”