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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


  • 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
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
Partners HealthCare Centers for Medicare & Medicaid Services

Partners Memory Care Initiative

Needs Assessment

Barriers to providing optimal patient care
Bar chart.


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