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

Patients

• 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

1-year Outcomes: Patients

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

2-year Outcomes: Patients

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

1-year Outcomes: Caregivers

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

2-year Outcomes: Caregivers

*Baseline and year 2 comparisons, p<0.01.

Spinoffs

• Infrastructure
  • Dementia Care Management Software
  • Website with caregiver training videos and webinars (http://dementia.uclahealth.org)
• 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