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Evidence-Based Models of Dementia Care

The NDCC encourages use the following comprehensive dementia care models. These models contribute to the rationale for reforming how dementia care is paid for, as reported in: Recommendations to Improve Payment Policies for Comprehensive Dementia Care.

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The Aging Brain Care (ABC) Program assists primary care providers (PCPs) in achieving the recommended standard of care in the care and management of people living with dementia and their care partners. Much of the ABC services are delivered by community health workers and dementia care coordinators at the home of the patients or by telephone, supervised by memory care physicians. They co-manage with PCPs, enhance self-management skills of the patient and care partner, maximize the coping behavior of the dyad, and support care for comorbid conditions. To date, the ABC Program has been rigorously evaluated during delivery to over 5,000 individuals in Eskenazi Health.

For more information on the ABC Program, please contact Shannon Effler (seffler@iupui.edu).

The Alzheimer’s and Dementia Care (ADC) Program, based on the award-winning UCLA Alzheimer’s and Dementia Care Program, is designed to help persons living with dementia (PLWD) and their loved ones meet the complex medical, behavioral, and social needs of Alzheimer’s disease and other types of dementia. Dementia Care Specialists who are Advanced Practice Providers (nurse practitioners or physician assistants) are at the heart of the program and work with the patient’s primary care doctor and/or specialists to create and implement a personalized care plan with extensive PLWD and caregiver support. For more information on ADC, please contact dementiaPM@mednet.ucla.edu.

Benjamin Rose Institute (BRI) Care Consultation is a consumer-directed, care-navigation and care-coaching program for both caregivers and persons living with dementia. Recommended by the Administration for Community Living and Best Practice Caregiving, BRI Care Consultation has been shown to be efficacious, effective, and feasible for delivery in 11 completed studies and is currently part of the D-Care comparative effectiveness pragmatic trial. The program is delivered by trained Care Consultants who are bachelors- or masters-prepared social workers, nurses, or other helping professionals. The program’s major components include an action plan, initial assessments and reassessments, and ongoing monitoring and support.

For more information on BRI, please contact Michelle Palmer (mpalmer@benrose.org).

The Care Ecosystem is a model of dementia care designed to provide personalized, cost-efficient care for persons with dementia and their caregivers. The Care Ecosystem model includes care team navigators (CTNs), clinicians with dementia expertise, care protocols, curated information and resources. Offering telephone and web-based intervention, Care Ecosystem was developed and studied across California, Nebraska, and Iowa via an award from the Center for Medicare and Medicaid Innovation from 2017–2022. The Care Ecosystem is currently being tested in a pragmatic clinical trial across six health systems.

For more information on the Care Ecosystem, please contact Michelle Barclay (michelle.barclay@ucsf.edu).

The Integrated Memory Care (IMC) program is a unique primary care practice co-created with family caregivers. Patients living with dementia receive geriatric primary care, dementia specialty care, and their families can receive caregiver support and education all in one location. Whether the person has a cold, needs medication management, or is experiencing dementia behaviors, specialized nurse practitioners will diagnose and treat with the goal of avoiding emergency department and hospital visits. To provide a broad range of services, the IMC utilizes an interprofessional team including nurse practitioners, registered nurses, geriatricians, social workers, and medical assistants to provide exemplary care coordination, education, and support. IMC is recognized as a patient-centered medical home by the National Committee for Quality Assurance (NCQA) and as an Age-Friendly Health System by the Institute for Healthcare Improvement.

For more information on IMC, please contact Amy Imes (amy.imes@emoryhealthcare.org).

Maximizing Independence (MIND) at Home’s Alzheimer’s and Dementia Care Coordination Program is an advanced care coordination program for community-living persons with dementia and cognitive impairment and their informal caregiver, delivered through an interdisciplinary, dementia capable collaborative team. Developed by researchers at Johns Hopkins University, the MIND program consists of a comprehensive set of assessments, tools and staff trainings for comprehensive dementia care.

For more information on MIND at Home, please contact Melissa Reuland (mreulan1@jhmi.edu).

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