Advisory Council August 2016 Meeting Presentation: UCLA Alzheimer's and Dementia Care Program

08/01/2016

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

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

Bar chart.

1-year Outcomes: Patients

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

2-year Outcomes: Patients

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

1-year Outcomes: Caregivers

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

2-year Outcomes: Caregivers

Line chart.
*Baseline and year 2 comparisons, p<0.01.

Spinoffs

  • Infrastructure
  • 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

Return to

National Alzheimer's Project Act Home Page

Advisory Council on Alzheimer's Research, Care, and Services Page

Advisory Council on Alzheimer's Research, Care, and Services Meetings Page

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