Monday, April 29, 2019
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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 |
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| 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"