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Advisory Council August 2016 Meeting Presentation: UCLA Alzheimer's and Dementia Care Program

Monday, August 1, 2016


The UCLA Alzheimer's and Dementia Care program

Lee A. Jennings, MD, MSHS--Evaluator
Zaldy Tan, MD--Medical Director
David B. Reuben, MD--Program Director

The UCLA Alzheimer's and Dementia Care Program

  • Clinical program with goals:
    • Maximize patient function, independence, & dignity
    • Minimize caregiver strain
    • Reduce unnecessary costs
  • Began in 2011 with philanthropic funds
    • Planned 250 patients
  • Round 1 CMMI Award July 2012--Dec 2015
    • To expand the program to 1,000 patients
  • Today, over 1800 patients enrolled
  • Approaches the patient and caregiver as a dyad; both need support
  • Recognizes that this care is a long journey
  • Provides comprehensive care based in the health system that reaches into the community
  • Uses a co-management model with Nurse Practitioner Dementia Care Manager (DCM) who does not assume primary care of patient
  • Works with physicians to care for patients by
    • Conducting in-person needs assessments
    • Developing and implementing individualized dementia care plans
    • Monitoring response and revising as needed
    • Providing access 24 hours/day, 365 days a year


  • Must have diagnosis of dementia
  • Live outside nursing home
  • Must have a referring/partnering UCLA physician

Community-based Organization (CBO) Services

  • Direct services to patients and families
    • Adult day care
    • Counseling
    • Case management
    • Legal and financial advice
  • Workforce development focusing on training family and caregivers
  • Paid for using voucher system

Enrollment to Date (7/20/16)

  • Patients enrolled: 1,825
  • Referrals waiting to be seen: 125
  • 1-year follow-ups conducted: 722
  • 2-year follow-ups conducted: 309
  • 3-year follow-ups conducted: 52

Patients in the Program

  • Mean age 82; 66% female
  • Diagnosis
    • Alzheimer's disease: 35%
    • Lewy-Body: 4%
    • Vascular: 4%
    • Other, mixed or unknown: 53%
  • Mean MMSE score 17.4
  • Caregiver: 34% spouse, 54% child
  • Dually insured 18%

Caregivers at Baseline

  • Depression & strain
    • 14% mod/sev depressive sx
    • 36% high stress
  • Low self-efficacy
    • 21% knew how to access services
    • 36% confident handling dementia problems
    • 26% have healthcare professional who helps work through dementia issues

Services Provided

  • Support group referral: 84%
  • Caregiver training: 75%
  • Refer to CBO: 56%
  • Recommend additional evaluation: 25%
  • Adjust medication: 16%
  • POLST: 20%

Caregiver Satisfaction

  • 90% felt the intake visit was time well spent
  • 91% felt concerns listened to and addressed
  • 92% would recommend the program to others

Physician Satisfaction

  • Valuable medical recommendations: 61%
  • Valuable behavioral recommendations: 85%
  • Enhanced MD relationship with patient: 68%
  • Saved MD time: 56%
  • Would recommend for other patients: 90%

Overall Dementia Quality of Care (ACOVE-3 and PCPI QIs)*

  • Community-based physicians 38%
  • Community-based physicians & NP 60%
  • UCLA Alzheimer's and Dementia Care 92%

* Based on medical record abstraction

Jennings LA, et al. J Am Geriatr Soc, Jun 2016. PMID: 27355394

1-year Changes in Caregiver Experience and Self-efficacy

Bar chart.

1-year Outcomes: Patients

Line chart.
For all baseline and year 1 comparisons, p<0.001.

2-year Outcomes: Patients

Line chart.
For all baseline and year 2 comparisons, p<0.001, except behavioral symptoms, p=0.07.

1-year Outcomes: Caregivers

Line chart.
For all baseline and year 1 comparisons, p<0.001.

2-year Outcomes: Caregivers

Line chart.
*Baseline and year 2 comparisons, p<0.01.


  • Infrastructure
  • Enhanced support for caregivers
    • I-CareD (personalized caregiver training program)
    • TIMEOUT@UCLA (student respite program)
    • Support Groups (English, Spanish, Early Onset, FTD, and Lewy Body)

Goals for the Future

  • Sustaining the program
  • Increasing the number served
  • Enhancing services
  • Disseminating the model

Costs of Program (per 1250 participants)

  • 5 FTE Nurse Practitioner DCMs
  • 2 FTE DCM Assistants
  • 0.5 FTE Medical Director
  • 1 FTE Program Administrator
  • 0.15 FTE Psychologist Support Group Leader
  • Software maintenance and supplies
  • Vouchers for community-based organizations

Comparative Costs of Program

UCLA ADC $1400/y ($4/d)
Donepezil (generic) $2190/y ($6/d)
Memantine $2880/y ($8/d)
Donepezil & Memantine $5070/y ($14/d)

Current Business Model

  • Bill for Medicare-allowed services (3%)
  • All other services free of charge
    • Care coordination with PCPs and CBOs
    • Telephone follow-up
    • Support groups
    • Education
  • Some institutional support, both in-kind and short-term funds (29%)
  • Ongoing grants and philanthropy (68%)

Barriers to Dissemination

  • Current Medicare coverage for program
    • For in-person visits, nurse practitioners are reimbursed 85% of what physicians are paid
    • For all clinical work that is not in-person, there is no reimbursement
    • No coverage for CBO services
  • Shortage of qualified nurse practitioners

In Summary

  • UCLA ADC Program proof of concept
    • Bringing program to scale
    • Longitudinal, co-management model
    • Patients and doctors like it
    • Filling a gap in care
  • Improving outcomes for patients and caregivers
  • But no current economic model under Medicare