Advisory Council April 2019 Meeting Presentation: Dementia Care Delivery Innovations

Monday, April 29, 2019

Printer Friendly Version in PDF Format (6 PDF pages)

Innovations in the Delivery of Dementia Care in a rapidly evolving health care landscape

Brent Forester, MD, MSc
Chief, Division of Geriatric Psychiatry, McLean Hospital
Medical Director, Behavioral Health and Evaluation & Research
Partners Population Health, Partners HealthCare
Associate Professor of Psychiatry,
Harvard Medical School

Disclosures

Grants and Research Support Last 12 months:
- National Institute of Aging
- Rogers Family Foundation, Spier Family Foundation
- Eli Lilly, Biogen
Consulting: Eli Lilly, Biogen

The Facts on Early Diagnosis and Disclosure

Pie Charts. Only about HALF of people with Alzheimer's are diagnosed. Pie 1=Among just those with the disease, only 33% are aware of their diagnosis. Pie 2=Of those diagnosed, only 45% of them or their caregtivers are aware of the diagnosis.

>80% of medical care for dementia occurs in general medical setting
Medicare reimbursement for dementia care planning: CPT Code 99483
Alzheimer's Association, 2018, Facts and Figures

Health Care System Transformation

Yesterday's Health Care
- Care built around the institution
- Payments incentivize more care
- Responsible for immediate outcome
- Grudging acceptance of cost
Today's Health Care
- Care built around the patient
- Payments incentivize better care
- Responsible for ongoing health
- Unable to sustain cost burden

Partners Accountable Care Organizations

Our contracts 7 years in...

Partners currently manages ~650,000 lives in various accountable care relationships.
41% of our primary care lives are part of our risk contracts

COMMERCIAL	MEDICAID	SELF-INSURED	MEDICARE
Alternative Quality Contract (AQC)	MassHealth ACO	Partners Plus	Next Generation ACO
~350k Covered Lives	~100k Covered Lives	~100k Covered Lives	~100k Covered Lives
Younger population; specialists critical to management	Population with significant disability, mental health, and/or substance use challenges	Commercial population, but Partners at full risk for cost and quality	Elderly population; care management central to trend management
Massachusetts Blue Cross Blue Shield Neighborhood Health Plan Harvard Pilgrim HealthCare Tufts Health Plan	Centers for Medicare & Medicaid Services MassHealth	Partners HealthCare	Centers for Medicare & Medicaid Services

Partners Memory Care Initiative

Needs Assessment

Barriers to providing optimal patient care

Other identified challenges:	Opportunities:
Distinguishing dementia from normal memory loss or depression Discussing dementia, delivering diagnosis Managing behavioral symptoms, medications Difficulty accessing specialty care when indicated	Improved care coordination Connection of patients to resources in community and at Partners Advance care planning Caregiver support

Goals & Objectives

Primary program goal:
- "To deliver high quality care for individuals with cognitive impairment by facilitating evidence-based assessment and treatment in the primary care setting, over the full illness trajectory, and for both patient and caregiver"
Specific aims:
- Support & train PCPs
- Improve patient health outcomes
- Improve caregiver health status
- Reduce total healthcare costs

Program Parameters

Collaborative Dementia Care:
Establish care team which collaborates with PCP to provide:
- Timely & regular patient assessment & severity stratification
- Assistance with diagnosis, disclosure, and difficult conversations
- Care planning
- Medication management
- Caregiver support
- Connection to specialties (neurology, geri psych) and other PHM programs (Collaborative Care, iCMP)
- Connection to community resources

Diagram showing how the care partners interact.

Full List of Objectives

Improved assessment
- Increase rate of diagnosis for (true positive) cases of dementia
- Improve rate of disclosure of diagnosis to patient/caregiver
Improved disease management
- Improve rate of advanced care planning
- Increased numbers of serious illness conversations
- Improved rate of medication review. Leading to:
  - Decrease in number of harmful medications prescribed (i.e. deprescribing)
  - Increase in number of evidence-based medications for dementia prescribed
- Improved access to specialty care and community resources
PCP training
- Improve PCP knowledge of and comfort with managing dementia, esp. behavioral symptoms
Health outcomes
- Reduction in caregiver stress and depression symptoms
- Improvement in patient health outcomes: depression, quality of life, behavioral & psychological symptoms of dementia (significant improvement in cognitive status not expected, but will be measured)
- Reduced healthcare system utilization: decreased number of ED visits and Inpatient days
Costs
- Decreased Total Medical Expenditure (TME)

Partners eCare: Interdisciplinary Patient Plan of Care (IPPOC)

Chronic Condition Management
Problem: Memory Impairment
- Patient Goals:
  - Adhere to medication regime
  - Adapt to lifestyle changes and restrictions
  - Participate in social and family activities
  - Patient identified goal
- Tasks:
  - Care Management regular follow up
  - Address psychosocial issues relating to memory impairment
  - Custom Intervention / Task
  - Consider referral to Dementia Care Coordinator- Alzheimer's Association