Care Coordination for People With Alzheimer's Disease and Related Dementias. Models of CARE Coordination


Approaches to care coordination were similar in most of the reviewed studies (Table 2). Briefly, a care coordinator was assigned to the care receiver/caregiver dyad to conduct a structured assessment, develop a care plan, provide ongoing support, and monitor their progress. For example, in the intervention described by Callahan et al. (2006), dyads met with the care manager on a bimonthly to monthly basis for symptom assessments and evaluations, caregivers were invited to participate in group support sessions led by a social psychologist, and care receivers were encouraged to engage in group chair-based exercise classes.

TABLE 2. Common Elements of Care Coordination Models in the 14 Reviewed Studies
  Element   Description
Care coordinator Generally a social worker, geriatric nurse practitioner, or nurse trained in dementia care.
Multidisciplinary care team In addition to the care coordinator, this team may include primary care providers, occupational & other therapists, social workers, geriatricians, or psychologists/psychiatrists. Provides care to the dyad or support to the care coordinator.
Structured needs assessment An interview, sometimes using specialized software; done in person at a clinic or at home or by telephone. Assesses the care receiver's health, functional & cognitive abilities, the home environment, supports in place, & the caregiver's needs & concerns. Evaluates whether specific services are needed, such as special equipment & adaptations, meals & other domestic help, respite services, adult day care, home care, & nursing home care.
Care plan Generally a written plan specifying treatments over the course of a set time period.
Referrals or direct arrangement of care   The care coordinator arranges care directly or refers patients/caregivers to providers.
Ongoing monitoring and support Monitoring to ensure the care plan is implemented. Often includes counseling, support groups, or other therapy for the caregiver.

Care coordinators were also responsible for either referring care receivers to medical or LTSS providers or directly arranging these services. Care coordinators were typically social workers, geriatric nurse practitioners, or registered nurses trained in dementia care. Care coordination was undertaken by a variety of health and social service organizations, including managed care companies, primary care practices, mental health programs, nursing homes, specialty clinics, and home care programs. The most common measured outcomes were service utilization, time to institutionalization, caregiver stress and burden, depression, quality of life, cognition, behavioral symptoms (such as aggression), and functional ability.

Ten programs coordinated both medical services and LTSS. One program focused on medical service coordination, and two programs focused only on LTSS.

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