Advisory Council April 2019 Meeting Presentation: Dementia Care 3.0

04/29/2019

ADVISORY COUNCIL ON ALZHEIMER'S RESEARCH, CARE, AND SERVICES

Monday, April 29, 2019

Printer Friendly Version in PDF Format (4 PDF pages)

 

Dementia Care 3.0
Sandra Eskenazi Center for Brain Care Innovation

  • MISSION:
    • Promote brain health through innovation, responsible care, rapid translational and implementation science, advanced analytics, and technology.
  • VISION:
    • Transforming brain health for all, now.

Potential Conflict of Interest in the past 12 months

  • Hold equity in
    • Preferred Population Health Management (PPHM), LLC.
    • RestUp, LLC
    • Advisory Board for Eisai, Genentech, Acadia

Dementia Care Plan

  • Goal of Care:
    • Advanced Care Plan
    • HABC-M-CG score < 15
  • Caregiver Stress Prevention Bundle
    • Monitoring caregiver needs
    • Monthly attendance of support group
    • Weekly 8 hour time-off caregiving tasks
    • Problem solving coaching
    • Crisis plan
  • Medication Management
    • Cholinesterase inhibitors
    • D/C medications with adverse cognitive effects
    • Medication adherence support
  • Transition care:
    • Check Hospital & ER Alerts every day
    • Coordinate with Inpatient services
      • Alert hospital team of presence of cognitive or mood problems
      • Medications conciliation
      • Connect with family caregiver
      • Request Geriatric consult (If available)
      • Coordinate post discharge transition
    • Post discharge care
      • Home visit within 72 hours of discharge
      • Medication reconciliation
      • Coordinate Home Care visit
      • Coordinate post hospital orders
      • Deliver Delirium protocol and handout

Callahan et al, Aging & Mental Health 2011; Boustani et al, Aging & Mental Health 2011; LaMantia et al, JAGS 2015

Work Force from 1.0 to 3.0

Today ABC 2.0: : M-F 8-5 p.m. about $ 100 p.m.p.m., focusing on dementia / depression
Future ABC 3.0: 24/7 about $ 50 p.m.p.m., almost all brain conditions
Pyramid: Top Row--MD; Second Row--RN & SW; Third Row--CCA; Bottow Row--Patients and informal caregivers. All four rows=3.0; Top, Second and Third Rows=2.0; Top and Second Rows=1.0.
p.m.p.m.=per member per month; MD=medical doctor; RN=registered nurse; SW=social worker; CCA=care coordinator assistant; eMR ABC=electronic medical record ageing brain care (a specialized software application for the model)

BCN -- Brain CareNotes

  • Offers integration with the clinical programs workflow
    • Secure bi-directional messaging, reminders
    • Remote monitoring of assessments by clinician
    • Plan of care embedded in app
  • Provides a comprehensive set of features for BPSD management
    • Creation of personal strategies
    • Tools for validated assessments
    • Evidence-based recommendations
    • Historic BPSD tracking
    • And more..

Scenario 1:

  • Caregiver receives a reminder
  • Logs in and views messages
  • Starts validated assessment
  • Continues assessment
  • Views final score report
  • Is prompted to send message about the score
  • Sends care coordinator score with personal message

Scenario 2:

  • Caregiver opens BCN
  • Browses Care Topics
  • Reads about Mealtime issues
  • Views Mealtime tips and advice
  • Selects a relevant tip
  • Saves the tip to "My CareNotes"

Thank you

mboustan@iu.edu

http://www.hii.iu.edu


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