Impact of the care coordination program "Partners in Dementia Care" on veterans' hospital admissions and emergency department visits

[DemStepCare: Risk-stratified support for primary care-based dementia care - evaluation from general practitioner's view]

OBJECTIVE

The innovation fund project DemStepCare aimed to optimize multi-professional care through case management, risk stratification, and crisis outpatient clinic. Here, the evaluation results from the perspective of the general practitioners are presented.

METHODS

A quantitative survey was carried out at three time points regarding acceptance, benefit assessment and sensitivity to dementia of the general practitioners. In addition, qualitative interviews were conducted.

RESULTS

Satisfaction with the overall project was high. Added value and relief factors were perceived and more effective and stable dementia care was achieved through collaboration with case management. Physicians reported increased subjective competence in diagnostics and disease management.

CONCLUSIONS

The results confirm the benefit and effectiveness of DemStepCare from general practitioner's perspective.

Telehealth Infrastructure, Accountable Care Organization, and Medicare Payment for Patients with Alzheimer's Disease and Related Dementia Living in Socially Vulnerable Areas

Background: Structural social determinants of health have an accumulated negative impact on physical and mental health. Evidence is needed to understand whether emerging health information technology and innovative payment models can help address such structural social determinants for patients with complex health needs, such as Alzheimer's disease and related dementias (ADRD). Objective: This study aimed to test whether telehealth for care coordination and Accountable Care Organization (ACO) enrollment for residents in the most disadvantaged areas, particularly those with ADRD, was associated with reduced Medicare payment. Methods: The study used the merged data set of 2020 Centers for Medicare and Medicaid Services Medicare inpatient claims data, the Medicare Beneficiary Summary File, the Medicare Shared Savings Program ACO, the Center for Medicare and Medicaid Service's Social Vulnerability Index (SVI), and the American Hospital Annual Survey. Our study focused on community-dwelling Medicare fee-for-service beneficiaries aged 65 years and up. Cross-sectional analyses and generalized linear models (GLM) were implemented. Analyses were implemented from November 2023 to February 2024. Results: Medicare fee-for-service beneficiaries residing in SVI Q4 (i.e., the most vulnerable areas) reported significantly higher total Medicare costs and were least likely to be treated in hospitals that provided telehealth post-discharge services or have ACO affiliation. Meanwhile, the proportion of the population with ADRD was the highest in SVI Q4 compared with other SVI levels. The GLM regression results showed that hospital telehealth post-discharge infrastructure, patient ACO affiliation, SVI Q4, and ADRD were significantly associated with higher Medicare payments. However, coefficients of interaction terms among these factors were significantly negative. For example, the average interaction effect of telehealth post-discharge and ACO, SVI Q4, and ADRD on Medicare payment was -$1,766.2 (95% confidence interval: -$2,576.4 to -$976). Conclusions: Our results suggested that the combination of telehealth post-discharge and ACO financial incentives that promote care coordination is promising to reduce the Medicare cost burden among patients with ADRD living in socially vulnerable areas.

Informing Dementia Support Programs That Serve Low-Income, Multilingual Communities in a Safety Net Health System: Use of Focus Groups to Identify Specific Needs

The Centers of Medicare and Medicaid Services recently announced a new voluntary nationwide model. This model aims to provide comprehensive, standard care for people living with dementia and their unpaid caregivers and to enhance health equity in dementia care. However, little is known about the needs of older adults with dementia and their caregivers in a multiethnic and multicultural patient population of a safety net health system. The aim of this study is to include their voices. We conducted four focus groups in English and Spanish to investigate the common needs and barriers unique to the care of patients within the Los Angeles County healthcare system. Using qualitative, iterative analyses of the transcripts, we identified four domains of concern from the dyads (persons with dementia and their caregivers): need for education for dyad-centered care, barriers to resources, dyad safety, and caregiver burden and insight. These domains are interconnected, and the way this patient population experiences these domains may differ compared to those in well-resourced or predominantly English-speaking healthcare settings. Therefore, the identified domains serve as potential building blocks for dementia support programs inclusive of underserved, multicultural populations.

Rates of 30-day revisit to the emergency department among older adults living with dementia: a systematic review and meta-analysis

OBJECTIVE

Older adults visit emergency departments (EDs) at higher rates than their younger counterparts. However, less is known about the rate at which older adults living with dementia visit and revisit EDs. We conducted a systematic review and meta-analysis to quantify the revisit rate to the ED among older adults living with a dementia diagnosis.

METHODS

We searched MEDLINE, Embase, and CINAHL, as well as gray literature, to identify observational studies reporting on older adults living with dementia that revisited an ED within 30 days of a prior ED visit. We calculated pooled rates of 30-day revisit as percentages using random effects models, and conducted stratified analyses by study data source, study population, and study period. We assessed between-studies heterogeneity using the I2 statistic and considered [Formula: see text] > 50% to indicate substantial heterogeneity. All analyses were performed in R software.

RESULTS

We identified six articles for inclusion. Percentages of 30-day ED revisit among older adults living with dementia ranged widely from 16.1% to 58.0%. The overall revisit rate of 28.6% showed significant heterogeneity. Between-studies heterogeneity across all stratified analyses was also high. By data source, 30-day revisit percentages were 52.3% (public hospitals) and 20.0% (administrative databases); by study population, revisit percentages were 33.5% (dementia as main population) and 19.8% (dementia as a subgroup). By study period, revisit percentages were 41.2% (5 years or greater) and 18.9% (5 years or less).

CONCLUSION

Existing literature on ED revisits among older adults living with dementia highlights the medical complexities and challenges surrounding discharge and follow-up care that may cause these patients to seek ED care at an increased rate. ED personnel may play an important role in connecting patients and caregivers to more appropriate medical and social resources in order to deliver an efficient and more rounded approach to care.

Dementia care navigation: A systematic review on different service types and their prevalence

BACKGROUND

Dementia Care Navigators (DCNs) are professionals without clinical training, who provide individualised emotional and practical support to people living with dementia, working alongside clinical services. Navigator services have been implemented but the service offered vary without a consistent overview provided. The aim of this narrative systematic review was to describe and compare existing service formats, and to synthesise evidence regarding their implementation and impacts.

METHODS

The review was registered on PROSPERO [CRD42021292518]. Three electronic databases were searched and included studies reported on a DCN service, defined as a service in which non-clinically trained workers provide personalised advice and support to people with dementia and/or carers in the community. Two independent reviewers screened abstracts and titles and read through full papers for inclusion. Risk of bias was assessed using the Standard Quality Assessment QualSyst.

RESULTS

We included 14 papers reporting on six studies. All services were US-based and only varied by integration and training provided. Studies reported different degrees of impact on service utilisation and on symptoms and mental well-being of people with dementia and their carers, with too little evidence to draw substantial/meaningful conclusions and studies employing different outcome measures. One study evidenced greater impacts on people with more advanced dementia compared to earlier stages.

CONCLUSIONS

DCN services have the potential to effectively provide non-clinical support to people with dementia and carers from the point of diagnosis. Further research from countries other than the USA, focusing on the impact on social care and social support service access and utilisation, and utilising similar established outcome measures are required.

An integrative review of measures of transitions and care coordination for persons living with dementia and their caregivers

Introduction

High rates of hospital visits and readmissions are common among persons living with dementia, resulting in frequent transitions in care and care coordination. This paper identifies and evaluates existing measures of transitions and care coordination for persons living with dementia and their caregivers.

Methods

This integrative review builds off a prior review using a systematic search of online databases (PubMed, EBSCO, CINAHL, PsycInfo, and Scopus) to identify records and locate reports (or articles) that use measures of care transitions and care coordination. Identified measures were compared to the Alzheimer's Association's Dementia Care Practice Recommendations to evaluate strengths and weaknesses of the measure in this population, such as if measures were person- and family-centered.

Results

Seventy-one reports using measures of transitions in care and care coordination for persons living with dementia and their caregivers were identified. There were multiple measures identified in some reports. Three main areas of measures were classified into: identification of the population (3 measures, 8 reports), transitional care and care coordination delivery (14 measures, 17 reports), and transitional care and care coordination outcomes (e.g., health-care use, cost, and mortality; 17 measures, 60 reports). A strength of the three main areas of measures was that a portion of the measures were person- and family-centered. Variability in the operational definitions of some measures and time intensiveness of collecting the measure (e.g., number of items, the time it takes to complete the items) were common weaknesses.

Discussion

Transitions and care coordination measures are varied across studies targeted at persons living with dementia and their caregivers. Existing measures focus heavily on outcomes, specifically health-care resource use, and cost, rather than the elements of transitional care or care coordination. Future measure development focused on care transitions and service coordination is needed.

Gatekeepers: The Association of Caregiving Network Characteristics With Emergency Department Use by Persons Living With Dementia

OBJECTIVES

Caregivers are typically enmeshed in networks of family and friends who assist with care, yet this network is largely neglected in research. In light of the fact that caregivers are key medical decision makers and play a critical role in how persons living with dementia (PLwDs) interface with the health care system, this study explores how features of the caregiver network relate to PLwD emergency department (ED) use.

METHODS

Using 2015 National Health and Aging Trends Study data linked with fee-for-service Medicare claims, we examine ED use in a nationally representative sample of community-dwelling persons aged 65 and older with dementia and at least 1 caregiver. We consider aspects of the caregiver network including membership (e.g., daughter in network), network size, hours of care received, and the presence of generalists and specialists (i.e., broad vs narrow functional assistance) as predictors of ED encounters among PLwD.

RESULTS

PLwDs were 81.5 years old on average, 50% were female, and 33% were non-White. Care networks including nonimmediate family members involved in task sharing for mobility and self-care difficulties and those with more generalists had significantly higher odds of an ED visit. Networks that only consisted of specialist caregivers had significantly lower odds of an ED visit.

DISCUSSION

Greater complexity of care networks increases risk of presenting to the ED for care. Better understanding how caregiving networks help PLwD interact with the health care system can inform intervention design and targeting in order to help care networks improve care coordination, management, and shared decision making.

The Association between Primary Care Practices' Structural Capabilities and Hospitalizations among Persons Living with Dementia

Background: Persons living with dementia (PLWD) are more likely to be hospitalized than individuals without dementia. Little is known about key features (i.e., structural capabilities) in primary care practices where PLWD receive care. This study assessed the relationship between structural capabilities (i.e., care coordination, community integration, and reminder systems) and hospitalizations among PLWD. Methods: We conducted a secondary analysis of cross-sectional data from 5001 PLWD in 192 practices and used three datasets: nurse practitioner surveys, Medicare claims, and Minimum Data Set. Using generalized estimating equations, we evaluated the association between structural capabilities and hospitalizations. Results: PLWD who received care from practices with care coordination were less likely to have hospitalizations (OR = 0.62, p < .05). No statistically significant associations were observed between community integration and reminder systems and hospitalizations. Conclusion: Primary care practices need to tailor structural capabilities to address the needs of PLWD to reduce hospitalizations.

Patient navigation programs for people with dementia, their caregivers, and members of the care team: a scoping review

OBJECTIVE

The main objective of this review was to map the literature on the characteristics of patient navigation programs for people with dementia, their caregivers, and members of the care team across all settings. The secondary objective was to map the literature on the barriers and facilitators for implementing and delivering such patient navigation programs.

INTRODUCTION

People with dementia have individualized needs that change according to the stage of their condition. They often face fragmented and uncoordinated care when seeking support to address these needs. Patient navigation may be one way to help people with dementia access better care. Patient navigation is a model of care that aims to guide people through the health care system, matching their unmet needs to appropriate resources, services, and programs. Organizing the available information on this topic will present a clearer picture of how patient navigation programs work.

INCLUSION CRITERIA

This review focused on the characteristics of patient navigation programs for people living with dementia, their caregivers, and the members of the care team. It excluded programs not explicitly focused on dementia. It included patient navigation across all settings, delivered in all formats, and administered by all types of navigators if the programs aligned with this review's definition of patient navigation. This review excluded case management programs.

METHODS

This review was conducted in accordance with JBI methodology for scoping reviews. MEDLINE, CINAHL, APA PsycINFO, Embase, and ProQuest Nursing and Allied Health databases were searched for published full-text articles. A gray literature search was also conducted. Two independent reviewers screened articles for relevance against the inclusion criteria. The results are presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram, and the extracted data are presented narratively and in tabular format.

RESULTS

Thirty-nine articles describing 20 programs were included in this review. The majority of these articles were published between 2015 and 2020, and based out of the United States. The types of sources included randomized controlled trials, quasi-experimental studies, and qualitative exploratory studies, among others. All programs provided some form of referral or linkage to other services or resources. Most dementia navigation programs included an interdisciplinary team, and most programs were community-based. There was no consistent patient navigator title or standard delivery method. Commonly reported barriers to implementing and delivering these programs were navigator burnout and a lack of coordination between stakeholders. Commonly reported facilitators were collaboration, communication, and formal partnerships between key stakeholders, as well as accessible and flexible program delivery models.

CONCLUSIONS

This review demonstrates variety and flexibility in the types of services patient navigation programs provided, as well as in the modes of service delivery and in navigator title. This information may be useful for individuals and organizations looking to implement their own programs in the future. It also provides a framework for future systematic reviews that seek to evaluate the effectiveness or efficacy of dementia navigation programs.

The Impact of Ambulatory Dementia Care Models on Hospitalization of Persons Living With Dementia: A Systematic Review

This systematic review presents an overview of the existing dementia care models in various ambulatory care settings under three categories (i.e., home- and community-based care models, partnership between health systems and community-based resources, and consultation models) and their impact on hospitalization among Persons Living with Dementia (PLWD). PRISMA guidelines were applied, and our search resulted in a total of 13 studies focusing on 11 care models. Seven studies reported that utilization of dementia care models was associated with a modest reduction in hospitalization among community-residing PLWD. Only two studies reported statistically significant results. Dementia care models that were utilized in specialty ambulatory care settings such as memory care showed more promising results than traditional primary care. To develop a better understanding of how dementia care models can be improved, future studies should explore how confounders (e.g., stage of dementia) influence hospitalization.

Use of Telephone- and Internet-Based Support to Elicit and Address Financial Abuse and Mismanagement in Dementia: Experiences from the Care Ecosystem Study

BACKGROUND

Financial mismanagement and abuse in dementia have serious consequences for patients and their families. Vulnerability to these outcomes reflects both patient and contextual factors.

OBJECTIVE

Our study aimed to assess how multidisciplinary care coordination programs assist families in addressing psychosocial vulnerabilities and accessing needed resources.

METHODS

Our study was embedded in a clinical trial of the Care Ecosystem, a telephone- and internet-based supportive care intervention for patients with dementia and caregivers. This program is built around the role of the Care Team Navigator (CTN), an unlicensed dementia care guide who serves as the patient and caregiver's primary point of contact, screening for common problems and providing support. We conducted a qualitative analysis of case summaries from a subset of 19 patient/caregiver dyads identified as having increased risk for financial mismanagement and abuse, to examine how Care Ecosystem staff identified vulnerabilities and provided support to patients and families.

RESULTS

CTNs elicited patient and caregiver needs using templated conversations to address common financial and legal planning issues in dementia. Sources of financial vulnerability included changes in patients' behavior, caregiver burden, intrafamily tension, and confusion about resources to facilitate end-of-life planning. The Care Ecosystem staff's rapport with their dyads helped them address these issues by providing emotional support, information on how to access financial, medical, and legal resources, and improving intra-familial communication.

CONCLUSION

The Care Ecosystem offers a scalable way to address vulnerabilities to financial mismanagement and abuse in patients and caregivers through coordinated care by unlicensed care guides supported by a multidisciplinary team.

Systematic Review of Dementia Support Programs with Multicultural and Multilingual Populations

Background: Dementia care programs have become more common due to a growing number of persons living with dementia and lack of substantial benefit from pharmacologic therapies. Cultural and language differences may present barriers to access and efficacy of these programs. In this article, we aimed to systematically review the current literature regarding outcomes of dementia care programs that included multicultural and non-English speaking populations. Methods: A systematic review was conducted using four scientific search engines. All studies included in the review are English language, randomized control trials evaluating various care coordination models. The initial search strategy focusing on studies specifically targeting multicultural and non-English speaking populations resulted in too few articles. We expanded our search to articles that included these populations although these populations may not have been the focus of the study. Results: Seven articles met inclusion criteria for final review. Measured outcomes included emergency room use, hospitalizations, provider visits, quality of life indicators, depression scores, and caregiver burden. Conclusions: Dementia care programs demonstrate significant ability to provide support and improve outcomes for those living with dementia and their caregivers. There is limited research in this field and thus opportunity for further study in underserved and safety net populations including more high-quality randomized controlled trials with larger sample sizes.

Disparities in Preventable Hospitalization Among Patients With Alzheimer Diseases

INTRODUCTION

System-level care coordination strategies can be the most effective to promote continuity of care among people with Alzheimer's disease; however, the evidence is lacking. The objective of this study is to determine whether accountable care organizations are associated with lower rates of potentially preventable hospitalizations for people with Alzheimer's disease and whether hospital accountable care organization affiliation is associated with reduced racial and ethnic disparities in preventable hospitalizations among patients with Alzheimer's disease.

METHODS

This study employed a cross-sectional study design and used 2015 Healthcare Cost and Utilization Project inpatient claims data from 11 states and the 2015 American Hospital Association Annual Survey. Logistic regression and the Blinder-Oaxaca decomposition method were used.

RESULTS

African American patients with Alzheimer's disease were less likely to be hospitalized at accountable care organization‒affiliated hospitals than White patients. Among patients with Alzheimer's disease who were hospitalized, hospital accountable care organization affiliation was associated with lower odds of potentially preventable hospitalizations (OR=0.86, p=0.02; OR=0.66, p<0.001 with propensity score matching) after controlling for patient characteristics, hospital characteristics, and state indicators. Hospital accountable care organization affiliation explained 3.01% (p<0.01) of the disparity in potentially preventable hospitalizations between White and African American patients but could not explain disparities between White and Latinx patients.

CONCLUSIONS

Evidence suggests that accountable care organizations may be able to improve care coordination for people with Alzheimer's disease and to reduce disparities between Whites and African Americans. Further research is needed to determine whether this benefit can be attributed to accountable care organization formation or whether providers that participate in accountable care organizations tend to provide higher-quality care.

Medicare's Bundled Payments For Care Improvement Initiative Maintained Quality Of Care For Vulnerable Patients

The Bundled Payments for Care Improvement (BPCI) initiative established four models to test whether linking payments for an episode of care could reduce Medicare payments while maintaining or improving quality. Evaluations concluded that model 2, the largest, generally lowered payments without reducing quality for the average beneficiary, but these global results could mask adverse findings among vulnerable subpopulations. We analyzed changes in emergency department visits, unplanned hospital readmissions, and all-cause mortality within ninety days of hospital discharge among beneficiaries with one or more of three vulnerable characteristics-dementia, dual eligibility for Medicare and Medicaid, and recent institutional care-in 105,458 beneficiary episodes in the period October 2013-December 2016. The results for twelve types of medical and surgical BPCI episodes were evaluated relative to results in matched comparison groups. Our findings suggest that BPCI model 2 did not adversely affect care quality for beneficiaries with vulnerabilities. While this conclusion does not discourage the further development of bundled payment models, policy makers should support ongoing research to ensure that vulnerable populations are not adversely affected by these approaches.

Key Lessons Learned in the Strategic Implementation of the Primary Care Collaborative Memory Clinic Model: A Tale of Two Regions

BACKGROUND

Primary care collaborative memory clinics (PCCMCs) address existing challenges in dementia care by building capacity to meet the needs of persons living with dementia within primary care. This paper describes the strategic implementation of the PCCMC care model in two regions within Ontario.

METHODS

Evaluation of this initiative included the completion of individual interviews (N = 32) with key informants to identify impacts associated with the PCCMCs and tracking of all referrals and assessments completed in the first nine months of clinic implementation.

RESULTS

The qualitative analysis of interview transcripts generated five major themes: (1) earlier identification of dementia and intervention; (2) increased capacity for dementia care within primary care; (3) better patient and caregiver experience with care; (4) improved continuity, integration and coordination and improved care; and (5) system efficiencies. Across both regions, 925 patients were referred to PCCMCs, of which 631 (68%) had been assessed during the evaluation period.

CONCLUSIONS

Strategic, regional implementation of PCCMCs provides a significant opportunity to support better integrated and coordinated dementia care.

Features of primary care practice influence emergency care-seeking behaviors by caregivers of persons with dementia: A multiple-perspective qualitative study

BACKGROUND

Persons with dementia use emergency department services at rates greater than other older adults. Despite risks associated with emergency department use, persons with dementia and their caregivers often seek emergency services to address needs and symptoms that could be managed within primary care settings. As emergency departments (EDs) are typically sub-optimal environments for addressing dementia-related health issues, facilitating effective primary care provision is critical to reduce the need for, or decision to seek, emergency services. The aim of this study is to explore how features of primary care practice influence care-seeking decisions by community-dwelling persons with dementia and familial caregivers.

METHODS

Semi-structured qualitative interviews were conducted with 27 key dementia-care stakeholders (10 primary care/geriatrics providers, 5 caregivers, 4 emergency medicine physicians, 5 aging service providers, and 3 community paramedics) from multiple health systems. Transcripts from audio recordings were analyzed using a thematic analysis framework to iteratively code and develop emergent themes. Features of primary care were also synthesized into lists of tangible factors leading to emergency care-seeking and those that help prevent (or decrease the need for) ED use.

FINDINGS

Stakeholders identified eight categories of features of primary care encompassing the clinical environment and provision of care. These collapsed into four major themes: (1) clinic and organizational features-including clinic structure and care team staffing; (2) emphasizing proactive approaches to anticipate needs and avoid acute problems-including establishing goals of care, preparing for the future, developing provider-patient/provider-caregiver relationships, and providing caregiver support, education, and resources to help prevent emergencies; (3) health care provider skills and knowledge of dementia-including training and diagnostic capabilities; and (4) engaging appropriate community services/resources to address evolving needs.

CONCLUSIONS

Features of primary care practice influence decisions to seek emergency department care at the system, organizational/clinic, medical, and interpersonal levels, particularly regarding proactive and reactive approaches to addressing dementia-related needs. Interventions for improving primary care for persons with dementia and their caregivers should consider incorporating features that facilitate proactive family-centered dementia care across the four identified themes, and minimize those leading to caregiver decisions to utilize emergency services.

Effect of Collaborative Dementia Care via Telephone and Internet on Quality of Life, Caregiver Well-being, and Health Care Use: The Care Ecosystem Randomized Clinical Trial

IMPORTANCE

Few health systems have adopted effective dementia care management programs. The Care Ecosystem is a model for delivering care from centralized hubs across broad geographic areas to caregivers and persons with dementia (PWDs) independently of their health system affiliations.

OBJECTIVE

To determine whether the Care Ecosystem is effective in improving outcomes important to PWDs, their caregivers, and payers beyond those achieved with usual care.

DESIGN, SETTING, AND PARTICIPANTS

A single-blind, randomized clinical trial with a pragmatic design was conducted among PWDs and their caregivers. Each PWD-caregiver dyad was enrolled for 12 months between March 20, 2015, and February 28, 2017. Data were collected until March 5, 2018. Study interventions and assessments were administered over the telephone and internet by clinical and research teams in San Francisco, California, and Omaha, Nebraska. Of 2585 referred or volunteer PWD-caregiver dyads in California, Iowa, or Nebraska, 780 met eligibility criteria and were enrolled. A total of 512 PWD-caregiver dyads were randomized to receive care through the Care Ecosystem and 268 dyads to receive usual care. All eligible PWDs had a dementia diagnosis; were enrolled or eligible for enrollment in Medicare or Medicaid; and spoke English, Spanish, or Cantonese. Analyses were intention-to-treat.

INTERVENTION

Telephone-based collaborative dementia care was delivered by a trained care team navigator, who provided education, support and care coordination with a team of dementia specialists (advanced practice nurse, social worker, and pharmacist).

MAIN OUTCOMES AND MEASURES

Primary outcome measure: Quality of Life in Alzheimer's Disease based on caregiver's rating of 13 aspects of PWD's well-being (including physical health, energy level, mood, living situation, memory, relationships, and finances) on a 4-point scale (poor to excellent). Secondary outcomes: frequencies of PWDs' use of emergency department, hospitalization, and ambulance services; caregiver depression (score on 9-Item Patient Health Questionnaire; higher scores indicate more severe depression); and caregiver burden (score on 12-Item Zarit Burden Interview; higher scores indicate more severe caregiver burden).

RESULTS

The 780 PWDs (56.3% female; mean [SD] age, 78.1 [9.9] years) and 780 caregivers (70.9% female; mean [SD] age, 64.7 [12.0] years) lived in California (n = 452), Nebraska (n = 284), or Iowa (n = 44). Of 780 dyads, 655 were still active at 12 months, and 571 completed the 12-month survey. Compared with usual care, the Care Ecosystem improved PWD quality of life (B, 0.53; 95% CI, 0.25-1.30; P = .04), reduced emergency department visits (B, -0.14; 95% CI, -0.29 to -0.01; P = .04), and decreased caregiver depression (B, -1.14; 95% CI, -2.15 to -0.13; P = .03) and caregiver burden (B, -1.90; 95% CI, -3.89 to -0.08; P = .046).

CONCLUSIONS AND RELEVANCE

Effective care management for dementia can be delivered from centralized hubs to supplement usual care and mitigate the growing societal and economic burdens of dementia.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02213458.

30-Day Emergency Department Revisit Rates among Older Adults with Documented Dementia

OBJECTIVES

Published literature on national emergency department (ED) revisit rates among older adults with dementia is sparse, despite anecdotal evidence of higher ED utilization. Thus we evaluated the odds ratio (OR) of 30-day ED revisits among older adults with dementia using a nationally representative sample.

DESIGN

We assessed the frequency of claims associated with a 30-day ED revisit among Medicare beneficiaries with and without a dementia diagnosis before or at index ED visit. We used a logistic regression model controlling for dementia, age, sex, race, region, Medicaid status, transfer to a skilled nursing facility after ED, primary care physician use 12 months before index, and comorbidity.

SETTING

A nationally representative sample of claims data for Medicare beneficiaries aged 65 and older who maintained continuous fee-for-service enrollment during 2015 and 2016. Only outpatient claims associated with an ED visit between January 2016 and November 2016 were included as a qualifying index encounter.

PARTICIPANTS

We identified 240 249 patients without dementia and 54 622 patients for whom a dementia code was recorded in the year before the index encounter in 2016.

RESULTS

Our results indicate a significant difference in unadjusted 30-day ED revisit rates among those with an ED dementia diagnoses (22.0%) compared with those without (13.9%). Our adjusted results indicated that dementia is a significant predictor of 30-day ED revisits (P < .0001). Those with a dementia diagnosis at or before the index ED visit were more likely to have experienced an ED revisit within 30 days (OR = 1.27; 95% confidence interval = 1.24-1.31).

CONCLUSION

Dementia diagnoses were a significant predictor of 30-day ED revisits. Further research should assess potential reasons why dementia is associated with markedly higher revisit rates, as well as opportunities to manage and transition dementia patients from the ED back to the community more effectively. J Am Geriatr Soc 67:2254-2259, 2019.

Can non-pharmacological interventions reduce hospital admissions in people with dementia? A systematic review

Background

People with dementia who are admitted to hospital have worse outcomes than those without dementia. Identifying interventions that could reduce the risk of hospitalisation in people with dementia has the potential to positively impact on lives of people with dementia. This review aimed to investigate whether there are non-pharmacological interventions that successfully reduce hospitalisation risk, length of stay and mortality in people with dementia.

Methods

7 electronic databases and trial registries were searched from inception to October 2018. We included randomised controlled trials that evaluated non-pharmacological interventions in out of hospital settings and targeted people with any type of dementia. All stages of the review process were performed by two reviewers. Risk of bias was assessed using the Cochrane Risk of Bias tool. We grouped studies based on intervention: care management, counselling/self-help, enhanced GP services or memory clinics, and physiotherapy or occupational therapy. Data were pooled within intervention categories using random effects meta-analysis.

Results

There was no evidence that any of the intervention categories were associated with reduced hospital admission or mortality. There was very weak evidence to suggest that care management interventions (mean difference, MD, -0.16, 95% CI -0.32, 0.01), physiotherapy/occupational therapy (MD -0.16, 95% CI -0.36, 0.03) and enhanced GP/memory clinics (MD -0.14, 95% CI -0.31, 0.03) were associated with small reductions in hospital stay. There was no evidence for an effect of counselling/self-help interventions on length of hospital stay.

Conclusions

Current evidence from randomised trials suggests no clear benefit or harm associated with any of interventions on risks of hospitalisation, duration of hospitalisation or death. Further research with the primary aim to reduce hospitalisation in people with dementia is required.

Findings From a Real-World Translation Study of the Evidence-Based "Partners in Dementia Care"

Background and Objectives

Numerous non-pharmacological programs for family caregivers and persons with dementia (PWDs) have been found efficacious in randomized controlled trials. Few programs have been tested in translation studies that assess feasibility and outcomes in less-controlled, real-world implementations. This translation study tested the impact of the partnership version of BRI Care Consultation, "Partners in Dementia Care (PDC)," on outcomes for PWDs and their family/friend caregivers. PDC was delivered via partnerships between the Louis Stokes Department of Veterans Affairs Medical Center and the Greater East Ohio Alzheimer's Association Chapter and the Western Reserve Area Agency on Aging. PDC is a personalized coaching program done by telephone, e-mail, and regular mail.

Research Design and Methods

For this translation study, the program was implemented in a manner that mirrored a non-research implementation. The study sample included 148 caregivers and 84 PWDs who used PDC for 12 months. Research data came from 2 structured telephone interviews, one before program implementation and a follow-up after program completion. PWDs and caregivers averaged 14 telephone contacts with Care Consultants over the 12-month study period, and 12 behavioral action steps to address problems or concerns.

Results

Repeated measures ANOVAs showed the use of PDC was related to significant improvements across several outcomes for PWDs and caregivers, with greater benefits in more difficult caregiving situations. Caregivers had decreased levels of isolation, physical health strain, unmet needs; and increased confidence in caregiving capacity, informal helpers, and support service use. PWDs had decreased embarrassment about memory problems and unmet needs; and increased informal support and community service use.

Discussion and Implications

Overall, improved outcomes for PWDs and caregivers in this translation study were similar to findings from previous randomized trials, and affirmed the value of the program when delivered as a regular service offering by health care and community service organizations.

The costs of dementia subtypes to California Medicare fee-for-service, 2015

INTRODUCTION

Dementia is among the costliest of medical conditions, but it is not known how these costs vary by dementia subtype.

METHODS

The effect of dementia diagnosis subtype on direct health care costs and utilization was estimated using 2015 California Medicare fee-for-service data. Potential drivers of increased costs in Lewy body dementia (LBD), in comparison to Alzheimer's disease, were tested.

RESULTS

3,001,987 Medicare beneficiaries were identified, of which 8.2% had a dementia diagnosis. Unspecified dementia was the most common diagnostic category (59.6%), followed by Alzheimer's disease (23.2%). LBD was the costliest subtype to Medicare, on average, followed by vascular dementia. The higher costs in LBD were explained in part by falls, urinary incontinence or infection, depression, anxiety, dehydration, and delirium.

DISCUSSION

Dementia subtype is an important predictor of health care costs. Earlier identification and targeted treatment might mitigate the costs associated with co-occurring conditions in LBD.

Integrated care for adults with dementia and other cognitive disorders

The importance of better care integration is emphasized in many national dementia plans. The inherent complexity of organizing care for people with dementia provides both the justification for improving care integration and the challenges to achieving it. The prevention, detection, and early diagnosis of cognitive disorders mainly resides in primary care, but how this is best integrated within the range of disorders that primary care clinicians are expected to screen is unclear. Models of integrated community dementia assessment and management have varying degrees of involvement of primary and specialist care, but share an emphasis on improving care coordination, interdisciplinary teamwork, and personalized care. Integrated care strategies in acute care are still in early development, but have been a focus of investigation in the past decade. Integrated care outreach strategies to reduce transfers from long-term residential care to acute care have been consistently effective. Integrated long-term residential care includes considerations of end-of-life care. Future directions should include strategies for training and education, early detection in anticipation of disease modifying treatments, integration of technological developments into dementia care, integration of dementia care into general health and social care, and the encouragement of a dementia-friendly society.

Cost impact of the transitional care model for hospitalized cognitively impaired older adults

AIM

The goal of this study was to compare postacute care costs of three care management interventions.

MATERIALS & METHODS

A total of 202 hospitalized older adults with cognitive impairment received either Augmented Standard Care, Resource Nurse Care or the Transitional Care Model. The Lin method was used to estimate costs at 30 and 180 days postindex hospital discharge.

RESULTS

The Transitional Care Model had significantly lower costs than the Augmented Standard Care group at both 30 (p < 0.001) and 180 days (p = 0.03) and significantly lower costs than Resource Nurse Care at 30 days (p = 0.02).

CONCLUSION

These findings suggest that the Transitional Care Model can reduce both the amount of other postacute care and the total cost of care compared with alternative services for cognitively impaired older adults. Clinicaltrials.gov : NCT00294307.

Geriatric Cooperatives in Southwestern Ontario: A novel way of increasing inter-sectoral partnerships in the care of older adults with responsive behaviours

Established in 2010, Geriatric Cooperatives support the evolving Behavioural Supports Ontario (BSO) programme in the South West Local Health Integration Network. Geriatric Cooperatives bring together members representing relevant cross-sectoral services and are tasked with identifying system gaps associated with the BSO target population as well as developing work plans specific to their local area, leveraging local capacity, and co-ordinating and improving linkages between sectors and services. The purpose of this study was to evaluate the partnerships formed over time within these Cooperatives in order to inform their ongoing development and sustainability. In 2012 and in 2015, Geriatric Cooperative members were invited to complete the Partnership Self-Assessment Tool (PSAT), a valid and reliable tool for evaluating collaborative processes and identifying areas in need of improvement. Scoring the PSAT involves the calculation of mean scores (ranging from 1 to 5) for each of six dimensions describing effective collaboration; higher mean scores reflect better functioning. Two psychometrically sound versions of the PSAT exist; the shorter version (PSAT-S) scores fewer items in three dimensions. Survey response rates for the three Cooperatives that were evaluated in both 2012 and 2015 were 70% in 2012 and 36% in 2015; 57% of members who completed the survey in 2015 were new Cooperative members. Both years, more than 25% of respondents selected "don't know" for three of the nine items used to score the administration and management dimension. Both PSAT and PSAT-S mean dimension scores across both years reflected that more effort is needed to maximise collaborative potential. Use of the PSAT has promoted a better understanding of how partnerships are functioning. Knowledge of where more work is required along with effective strategies to overcome weak areas and gaps in functioning has the potential to ensure that these Cooperatives are successful.

Engagement of Veterans With Dementia in Partners in Dementia Care: An Evidence-Based Care Coordination Program

This study describes engagement of veterans with dementia in an evidence-based care coordination intervention called Partners in Dementia Care (PDC). PDC uses a person-centered approach that encourages participation by individuals with dementia (IWDs), despite their cognitive impairment. PDC also targets primary family or friend caregivers, who often are the main user of the program. Of the total 316 IWDs, 202 passed a mental status screening and were considered to have engagement potential. The study of actual engagement was based on data from IWDs' PDC records, combined with data from structured research interviews. Approximately 80% of IWDs with engagement potential had a minimum level of actual engagement in PDC. A smaller subsample was more actively engaged, as indicated by assigned and/or accomplished action steps. Younger IWDs and those self-reporting more memory difficulties had higher levels of engagement. Results describe one example of the extent and limits of IWD engagement in psychosocial interventions.