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Advisory Council April 2017 Meeting Presentation: Clinical Care Subcommittee

Monday, April 17, 2017

Printer Friendly Version in PDF Format (9 PDF pages)


Clinical Care Subcommittee Report

Clinical Care Subcommittee Members

  • Ellen Blackwell
  • Gary Epstein-Lubow
  • Bruce Finke
  • John Hsiao
  • Melinda Kelley
  • Rohini Khillan
  • Shari Ling
  • Erin Long
  • Myriam Marquez
  • Helen Matheny
  • Ron Petersen
  • Marianne Shaughnessy
  • Joan Weiss



  1. The National Plan should continue to promote early detection and diagnosis of AD/ADRD by encouraging cognitive assessment while also working to confirm measurement strategies to track progress. Specifically, within the next year, CMS should implement the new quality measure: "Cognitive Impairment Assessment Among At-Risk Older Adults: Percentage of patients age 75 years or older at the start of the measurement period with documentation in the EHR at least once during the measurement period of: (1) results from a standardized cognitive impairment assessment tool; or (2) a patient or informant interview."

  2. Federal agencies should offer and support continuing education efforts that improve healthcare providers' ability to recognize early signs of dementia, including Alzheimer's disease, and to offer counseling to individuals and their care partners, as well as connect them to local services and resources. Sessions should enhance healthcare provider awareness and understanding of the Medicare Annual Wellness Visit, knowledge of validated cognitive assessment tools, methods for reporting all dementia-related quality measures active in the Quality Payment Program, and the Cognitive Impairment Assessment and Planning code G0505.

  3. CMS should annually report data by state/region and by diagnosis regarding the use of the new G0505 billing code with long description: "Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, in office or other outpatient setting or home or domiciliary or rest home."

  4. The Advisory Council on Alzheimer's Research, Care and Services should devote one meeting to advancing the work ASPE has conducted with RTI on defining best practices for comprehensive dementia care. This meeting should include: 1) an in-depth description of the Examining Models of Dementia Care report and appendixes; 2) federal agency reporting of current innovative services for persons with dementia and their caregivers; 3) non-federal reporting from health systems and/or payers of exemplar population health solutions for dementia care; and 4) Advisory Council discussion of next steps to advance consensus definitions of best practice models, including measurement targets for clinical outcomes and value-based outcomes concerning cost and the care experience.


    Sandra Eskenazi Center for Brain Care Innovation
    Aging Brain Care Program

    Through decades of research completed at Eskenazi Health, we have developed the Aging Brain Care Program (ABC). ABC supports primary care providers in the specialized diagnosis and management of patients with cognitive impairment such as Alzheimer's disease, delirium and post critical illness cognitive and emotional problems.

    Our team utilizes an evidence-based collaborative care model to deliver brain care-focused population health management services to patients and their informal caregivers.

    We specialize in serving individuals with cognitive and emotional problems including:

    • Alzheimer's Disease
    • Mild Cognitive Impairment
    • Delirium
    • ICU Survivors
    • Depression


    Our Multi-disciplinary Care Team:

    • MD
    • Licensed Clinicians: RN, Social Worker, Psychologist
    • Community Health Workers: Care Coordinator Assistant
    • Patients and Informal Caregivers


    Non-licensed Care Coordinator Assistants are the primary liaison between the care team, our patients and their informal caregivers.

    • Conduct visits anywhere in the community convenient to the patient and their informal caregivers
    • Care is delivered through a variety of mechanisms including in person, phone and email


    Personalized BRAIN Care Services

    The ABC team creates a personalized Brain Care Plan and delivers care in clinic, home and community settings.

    All patients and their informal caregivers receive brain care management services focused on improving self-management, problem solving and coping skills.

    1. Patient and family education and counseling
    2. Data collection via standardized tools to identify and address changes in brain health
    3. Coordination of care transitions across multiple settings
    4. Design and delivery of person-centered, non-pharmacological interventions to reduce physical and psychological burden for both patients and their informal caregivers
    5. Modification of physical and social environment
    6. Engagement of palliative and hospice care as appropriate


    The ABC care delivery platform achieves the Triple Aim: Better brain care for individuals, better brain health for populations and lower per capita cost.


    The UCLA Alzheimer's and Dementia Care Program

    • Goals are to:
      • Maximize patient function, independence, & dignity
      • Minimize caregiver strain
      • Reduce unnecessary costs
    • Approaches the patient and caregiver as a dyad; both need support
    • Provides comprehensive care based in the health system that reaches into the community
    • Uses a co-management model with Nurse Practitioner Dementia Care Manager 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
    • Works with Community-base Organizations
      • Providing direct services to patients and families
      • Training family and caregivers



    • Fewer patient behavioral symptoms (1 year)
    • Less patient depression (1 & 2 years)
    • Reduced caregiver distress (1 & 2 years)
    • Lower caregiver depression (1 & 2 years)
    • Some reduced utilization and cost savings*
    • Reduced long-term care facility admissions


    * Final results are pending

  5. CMS should use the results of the Center for Medicare and Medicaid Innovation's (CMMI) dementia demonstration projects, combined with definitions of best practices for comprehensive dementia care, to create a fixed Per Beneficiary Per Month (PBPM) payment for reimbursement of comprehensive dementia care services. The first target for this PBPM payment model should be community dwelling persons with dementia and their care partners who are not eligible for (or do not have access to) a Program of All-Inclusive Care for the Elderly (PACE).

    CMS should establish a system for determining that clinical entities receiving PBPM payments have the ability to supply all essential elements of comprehensive dementia care. Congress and/or federal agencies should authorize and/or designate funding to conduct large-scale evaluation of the PBPM payment model for comprehensive dementia care; and, if the evaluations replicate the value proven by CMMI dementia demonstration projects, then CMS should implement the PBPM model nationwide.

  6. Changes to national healthcare must ensure continuation of support that is critical to people with dementia and their caregivers, including Medicare annual wellness visits that include cognitive assessment, protection for pre-existing conditions, funding for person- and family-centered* research on dementia, and support for innovative models of care.

    *The CMS Person and Family Centered Engagement Strategy report (Nov. 2016) defines "family" broadly to include participants in a person's health care including informal caregivers, along with the primary caregivers of persons who are in need of the support of their caregivers to make informed health care decisions.

  7. Federal agencies, national health and aging organizations, states, and other industry stakeholders should identify ways to implement recommendations that result from the October 2017 National Research Summit on Care, Services and Supports for Persons with Dementia and their Caregivers.

April 17, 2017 -- Advisory Council Meeting #24

The meeting was held on Monday, April 17, 2017, in Washington, DC. The Advisory Council spent the majority of the April meeting considering recommendations made by each of the three subcommittees for updates to the 2017 National Plan. Afternoon presentations included a presentation on results from a research project on dementia care components, planning progress towards a Care and Services Summit, and federal workgroup updates. Material available from this meeting is listed below and is also available at

Comments and questions, or alerts to broken links, should be sent to


General Information




Presentation Slides



  • Welcome, LTSS, and Clinical Care Recommendations -- [Video]

  • Research Recommendations, Council Discussion/Vote, Overview of Legislative Processes -- [Video]

  • Public Comments and Examining Models of Dementia Care -- [Video]

  • Care Summit Update and Federal Workgroup Updates -- [Video]