Advisory Council August 2016 Meeting Presentation: Indiana University Dissemination of the Aging Brain Care Program

08/01/2016

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

Monday, August 1, 2016

 

Indiana University Dissemination of the Aging Brain Care Program

Malaz Boustani, MD, MPH
Founding Director, Chief Innovation & Implementation Officer,
Sandra Eskenazi Center For Brain Care Innovation
Indiana University Center for Health Innovation and Implementation Science

IU Team

  • Mentors & peers
    • Chris Callahan
    • Greg Sachs
    • Mary Austrom
    • Siu Hui
    • Daniel Clark
    • Su Gao
    • Lisa Harris
    • Patrick Monahan
    • Wanzhu Tu
    • Anthony Perkins
  • Mentees:
    • Noll Campbell
    • Babar Khan
    • Nicole Fowler
    • Michael LaMantia
    • Richard Holden
    • Daniel Bateman
    • Sophia Wong
    • Ashley Overlay
    • Nadia Adams
    • Cathy Alder
    • Ben Zarzour

 

  • Potential Conflict of Interest in the past 12 months
    • Hold equity in a preferred population health management (PPHM), LLC. PPHM is the distributing network for the IU ABC program.
    • Member of the Beacon Advisory Board for Astra-Zneca.

 

  • Source of Funding:
    • For Brain Care Discovery:
      • K23AG026770; R01AG029884; R01AG040220; R01AG034205; P30AG024967; R01HS019818; and R01HS10884.
    • For Brain Care Delivery:
      • R24MH080827; 1C1CMS331000-01-00; 1L1CMS331444-01-00; and Eskenazi Health Foundation.

Objectives

  • Describe the structure, the tools, the staffing models, and effectiveness of the IU Aging Brain Care model.

Indiana University Reaction

  • Developed the Aging Brain Care Model (ABC beta ) (2000-2001).
  • Evaluated the model in RCT* (2001-2006).
  • Translated the model into a local clinical program (ABC 1.0) (2007).
  • Served 1,000 patients in Indianapolis (2012).
  • Developed a scalable version (ABC 2.0) (2012).
  • Served 5,000 patients in Indiana (2015).
  • Active distribution of the ABC 2.0 (2015)
  • Developing an advanced scalable version (ABC 3.0) (2016)

*RCT: Randomized Controlled Trial

The Aging Brain Care Model (ABC beta)

  • Primary Care Clinician (Hospitalists):
    • detect and treat delirium
    • detect and treat BPSD
    • Enhance cholinergic system by
      • Prescribe ChEIs
      • Discontinue Anticholinergic
  • Caregiver Focus:
    • Problem solving skills
    • Counseling
    • Respite care
    • Support group
  • Expert Team:
    • Geriatrician
    • Social Psychologist
    • GeroPsychiatrist
  • General Environmental Modification:
    • Medication adherence support
    • Home safety assessment

BPSD: Behavioral and psychological symptoms
ChEIs: Cholinesterase inhibitors

Callahan et al, JAMA 2006; Austrom et al, Gerontologist 2004; Boustani et al, JCIA 2006

Work Force for ABC Model 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

  • ABC 1.0 -- MD; RN & SW
  • ABC 2.0 -- MD; RN & SW; CCA
  • ABC 3.0 -- MD; RN & SW; CCA; Patients and informal caregivers

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)

IT Support of ABC Model from 1.0 to 3.0

  • ABC 1.0 -- MD, eMR-ABC; RN / SW + eMR-ABC
  • ABC 2.0 -- MD, eMR-ABC; RN / SW + eMR-ABC; Care Coordinator Assistants + eMR-ABC
  • ABC 3.0 -- MD, eMR-ABC; RN / SW + eMR-ABC; Care Coordinator Assistants + eMR-ABC; Informal Caregiver + AVATAR

Standardized Minimum ABC 2.0 Care

  1. Check Hospital & ER Alerts every day
  2. 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
  3. 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
  4. Ongoing Aging Brain Care
    • Manage Depression
      • Problem Solving Therapy
      • Pharmacotherapy
      • Cognitive behavioral Therapy
    • Manage Cognitive Impairment
      • Cholinesterase inhibitors (if needed)
      • D/C medications with adverse cognitive effects (Anticholinergics, Histamine 2 antagonists, Benzodiazepines)
      • Caregiver problem solving coaching
      • Medication adherence support

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

The Current Tools of ABC 2.0

  • Mobile office
  • HABC Monitor for both self and Caregiver report
  • eMR-ABC population management software
  • Mobile HABC App for Informal Caregiver
  • ABC Replication Manual
  • ABC Caregiver Booklet
  • Anticholinergic Cognitive Burden Scale

LaMantia et al JAGS 2015; Frame et al eGEMS 2013; Monahan et al, JCIA 2010; Monahan et al JCIA 2012; Boustani et al, JCIA 2009

The ABC beta version Efficacy

  • NNT = 3.7
  • 7 NPI point improvement
  • Each 1 point decline in NPI = $250-$400 in health care expenses
  • Potential saving 1750-$2800 per patient
  • Improvement in family stress
Bar chart.
Callahan, Boustani et al, JAMA 2006

NNT: Number Need to Treat; NPI: Neuropsychiatric Inventory; CG: Caregiver

ABC 1.0 Performance

The Acute Care Service Utility Domain ABC PCC
% patients with at least one ER visit 28% 49%
Total number of ER visits 124 1143
% patients with at least one hospitalization 13% 26%
Total number of hospitalizations 45 438
Mean/Median length of hospital stay 5 / 4 7 / 4
ABC; Aging Brain Care patients; PCC: primary care center patients
Boustani et al, Aging & Mental Health 2011

 

The Quality of Care Indicator Domain ABC PCC
% seen at ER again within one week 14% 15%
% re-hospitalized within 30 days of discharge 11% 20%
% with at least one order of definite anticholinergics 19% 40%
% with at least one order of neuroleptics 5% 5%
% with at least one order of anti-dementia drugs 55% 13%
% with at least one order of antidepressant drugs 68% 48%
% with at least one order of definite anticholinergics and anti-dementia drugs 16% 32%
% with at least one LDL order 82% 72%
% of patients with LDL < 130 45% 23%
% with at least one HbA1c order 78% 62%
% of patients with HbA1c < 8 78% 51%
% with last systolic BP < 160 27% 24%
ABC; Aging Brain Care patients; PCC: primary care center patients
Boustani et al, Aging & Mental Health 2011

ABC 1.0 Annual Cost Savings Per Patient

Bar chart.
Total Cost Savings Per Patient Low Mid High
$2,885 $3,474 $4,227

ABC 2.0 Performance

Health Outcomes
Full Dementia Care Giver Responders at 12 months 66%
Full Major Depression Patients Responders at 12 months 51%
LaMantia et al, JAGS 2015

ABC DistributionPreferred Population Health Management, LLC

  • On-boarding of scalable and existing workforce within the AAAs. (multiple Mini Interview)
  • Training and ongoing management and support of the scalable workforce (combined experiential adult learning based coaching)
  • Ongoing Zoom-in & Zoom-out monitoring of the performance of the entire population to allow both complex case management and comprehensive resource allocation for the entire population at Risk (Population Health Logistic software)
  • Evidence-based clinical pathway to mange the complex cognitive, functional, behavioral and psychological needs of both the client (member suffering from the disease) and their family caregiver.

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