Advisory Council May 2021 Meeting Presentation: Successful Programs

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

Monday, May 3, 2021

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Disseminating and Implementing Successful Dementia Care Programs

David B. Reuben, MD
Archstone Professor of Geriatrics
David Geffen School of Medicine at UCLA

The Next 10 Minutes

• The "Who"?: Population-based dementia care
• The "What": New models of dementia care
• The "How": Drivers of and barriers to adoption of new models
• Policy Implications and actions

Who: Population-based Dementia Care Model

Total # & Yearly Minimum Utilization By Risk Tier
One size does not fit all

What: Models of Dementia Care

• Caregiver support only (e.g., REACH II)
• Comprehensive models focus on patient and caregiver and have:
  • Continuous monitoring and assessment
  • Ongoing care plans
  • Psychosocial interventions
    • Aimed at person living with dementia
    • Aimed at caregivers
  • Self-management
  • Medication management (some comm-based don't)
  • Treatment of related conditions
  • Coordination of care

Examples of New Models of Comprehensive Care for Dementia

• Community-based
  • BRI Care Consultation
  • MIND at Home (Hopkins)
  • The Care Ecosystem (UCSF)
• Health System-based
  • Indiana University Healthy Aging Brain Center (HABC)
  • The UCLA Alzheimer's and Dementia Care Program (UCLA ADC)
  • Integrated Memory Care Clinic (Emory)
• Vary in base of operations, key personnel, process, expense, clinical benefits, and cost returns

Comparison of Some Dementia Care Models

Structure and Process	BRI CC	Care Ecosystem	MIND	HABC	UCLA ADC	IMCC
Key personnel	SW, RN, MFT	Non-licensed APN, SW, Pharmacist	Non-licensed RN, MD	Non-licensed MD, SW, RN, Psychologist	NP, PA, MD	APN
Key personnel base	CBO	Community	Community	Health system	Health system	Health system
Face-to-face visits	No	No	Yes	Yes	Yes	Yes
Access 24/7/365	No	No	No	Yes	Yes	Yes
Communication with PCP	Mail, fax	Fax, phone	Phone, mail, fax	EHR, phone, mail	EHR, phone	N/A
Order writing	No	No	No	Yes	Yes	Yes
Benefits
High quality of care	N/A	N/A	N/A	Yes	Yes	Yes
Patient benefit	Yes	Yes	Yes	Yes	Yes	NS
Caregiver benefit	Yes	Yes	Yes	Yes	Yes	NS
Costs of program	++	++	+++	+++	++++	++++
Cost savings, gross	++	++	None	++	++++	++++

How: Characteristics of an Innovation

• Relative advantage
• Compatibility
• Complexity
• Trialability
• Observability

Barriers to Adoption and Implementation

• Inertia and lack of insight
• Costs:
  • Are up-front while savings are downstream
  • Insufficient revenue
  • Savings may accrue to different stakeholders
• Training
• Community-based partners
  • Identification and vetting
  • Payment
  • Communication

Policy Implications

• Several evidence-based or promising models that have had minimal dissemination, even within managed care
• Adequate payment for services provided has been a major barrier to adoption
• Even with commitment to adopt, training beyond basic discipline skills is needed
• Integration of services provided by community-based organizations has been haphazard and poorly paid
• Additional models of care, particularly addressing underserved and remote populations need to be developed

Policy Actions

• Although additional research will help determine effectiveness, there is sufficient evidence to begin broad dissemination of REACH II and collaborative care models
  • APMs: Comprehensive Care for Alzheimer's Act
  • FFS
  • Medicare Advantage
• Fund training in dementia care
• Develop mechanisms to pay community-based organizations for services provided to individual persons
• Develop and test models for special populations