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Advisory Council April 2019 Meeting Presentation: Dementia Care 3.0

Monday, April 29, 2019

Printer Friendly Version in PDF Format (4 PDF pages)


Dementia Care 3.0
Sandra Eskenazi Center for Brain Care Innovation

    • Promote brain health through innovation, responsible care, rapid translational and implementation science, advanced analytics, and technology.
    • Transforming brain health for all, now.

Potential Conflict of Interest in the past 12 months

  • Hold equity in
    • Preferred Population Health Management (PPHM), LLC.
    • RestUp, LLC
    • Advisory Board for Eisai, Genentech, Acadia

Dementia Care Plan

  • Goal of Care:
    • Advanced Care Plan
    • HABC-M-CG score < 15
  • Caregiver Stress Prevention Bundle
    • Monitoring caregiver needs
    • Monthly attendance of support group
    • Weekly 8 hour time-off caregiving tasks
    • Problem solving coaching
    • Crisis plan
  • Medication Management
    • Cholinesterase inhibitors
    • D/C medications with adverse cognitive effects
    • Medication adherence support
  • Transition care:
    • Check Hospital & ER Alerts every day
    • 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
    • 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

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

Work Force 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
Pyramid: Top Row--MD; Second Row--RN & SW; Third Row--CCA; Bottow Row--Patients and informal caregivers. All four rows=3.0; Top, Second and Third Rows=2.0; Top and Second Rows=1.0.
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)

BCN -- Brain CareNotes

  • Offers integration with the clinical programs workflow
    • Secure bi-directional messaging, reminders
    • Remote monitoring of assessments by clinician
    • Plan of care embedded in app
  • Provides a comprehensive set of features for BPSD management
    • Creation of personal strategies
    • Tools for validated assessments
    • Evidence-based recommendations
    • Historic BPSD tracking
    • And more..

Scenario 1:

  • Caregiver receives a reminder
  • Logs in and views messages
  • Starts validated assessment
  • Continues assessment
  • Views final score report
  • Is prompted to send message about the score
  • Sends care coordinator score with personal message

Scenario 2:

  • Caregiver opens BCN
  • Browses Care Topics
  • Reads about Mealtime issues
  • Views Mealtime tips and advice
  • Selects a relevant tip
  • Saves the tip to "My CareNotes"

Thank you