NATIONAL PLAN TO ADDRESS ALZHEIMER'S DISEASE: 2017 UPDATE. Strategy 2.E: Explore the Effectiveness of New Models of Care for People with Alzheimer's Disease and Related Dementias

09/01/2017

Alzheimer's Disease Supportive Services Program. ACL continues to support state grantees and their partners in the implementation of dementia-capable LTSS systems. The grantees are lead dementia agencies within their states, in direct response to recommendations from the Advisory Council. Grantees are: (1) developing a "no wrong door" service system; (2) ensuring access to comprehensive, sustainable services for people with dementia and their family caregivers; and (3) implementing evidence-based or informed interventions as part of their programs. In 2016, ADSSP expanded to include two new states -- Texas and Michigan. This program's focus on dementia-capability and direct services through evidence-based interventions and targeted training is in direct response to the recommendations of the Advisory Council. ACL anticipates continuation of the ADSSP with new grants in 2017.

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Alzheimer's Disease Initiative-Specialized Supportive Services. ACL continues to support 32 Alzheimer's Disease Initiative-Specialized Supportive Services (ADI-SSS) grantees and their partners, which are located across the country and in Puerto Rico. The grantees are operating within dementia-capable systems and implementing new programs designed to provide more effective services to: (1) individuals living alone in the community with dementia; (2) individuals with IDD who have or are at-risk of developing dementia; (3) caregivers who need behavioral symptom management training or expert consultations to help them care for family members; and (4) provision of effective care/supportive services for individuals living with moderate to severe AD/ADRD and their caregivers. Grantees include a broad range of existing dementia-capable public and private entities. Grantees have tailored their programs to address service gaps in the communities they serve, including implementation of evidence-based and evidence-informed interventions. ACL anticipates the continuation of the ADI-SSS program, with new funding in 2017.

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ACL National Alzheimer's and Dementia Resource Center. ACL continues to fund a resource center that supports ACL grantees, their partners, and the larger Aging and Disability Networks in developing and implementing dementia-capable programs, dementia-friendly communities, specialized supportive services, and evidence-based programs. In addition to providing technical assistance, the National Alzheimer's and Dementia Resource Center (NADRC) manages an annual webinar series that is open to the general public, writes issue briefs on program-related topics, and evaluates and summarizes program results. NADRC staff also manages and facilitates grantee learning opportunities that result in resources that are beneficial to program activities and also made available to the general public. The NADRC website is home to numerous resources developed both in house and through agency grant programs.

For more information, see:

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Examining Models of Dementia Care. ASPE has completed a study examining dementia care models across settings using a framework to understand what providers are doing to provide care to individuals living with dementia and their families. The project is intended to better understand what "innovative" dementia care providers have in common and what practices may inform future understandings of quality dementia care. The project involves an environmental scan of best practices in dementia care, and a series of five case studies conducted across the country and in a range of dementia care settings. The results will inform future research related to developing quality measures and standards. ASPE has also conducted additional work to review the literature on outcomes of models or programs for dementia care to better understand how effective they are at improving the quality of life or health for people living with dementia and/or their caregivers.

For more information, see:

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Georgia Alzheimer's and Related Dementias State Plan. The Georgia Alzheimer's and Related Dementias (GARD) State Plan Advisory Group continues to meet to implement the GARD State Plan and to create a more dementia-capable Georgia. In June 2016, the Georgia Department of Human Services Division of Aging Services hired the very first GARD State Plan Coordinator. There are currently six workgroups made up of stakeholders from various sectors including health care, social services, and public policy. These workgroups include: Workforce Development; Service Delivery; Public Safety; Outreach and Partnerships; Policy; and Healthcare, Research and Data Collection. The current initiatives of GARD are focused on improved dementia education and training, implementation of person-centered care, and early and accurate diagnosis of dementia.

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Minnesota: Dementia-Capable State. Minnesota is building a dementia-capable state through the synergistic efforts of a host of dementia collaborations including:

  • The ACT on Alzheimer's® Collaborative's many accomplishments include: (1) Dementia-Friendly Communities now at 40 and counting; (2) Dementia Curriculum developed by leading experts in Minnesota; and (3) culturally infused Provider Practice Guidelines, 1,500 physicians and care coordinators have trained in these dementia care best practices. In Minnesota, the Health Care Summit advanced the adoption of the practice guidelines in health care systems with three major health care organizations leading the way and more in the wings. The state's Caregiver initiative lead to the funding of the Dementia Grants program where culturally sensitive caregiver education and services are targeted.
  • National Family Caregiver Support Program Act -- Minnesota has developed a statewide network of over 100 dementia-capable caregiver consultants who have or are completing the Minnesota culturally infused Caregiver Consultation training and Advanced Dementia-Capability training online and in-person training. Also, through Minnesota's current ADI-SSS grant the Resources for Enhancing Alzheimer's Caregivers' Health (REACH) Community is being embedded as a routine caregiver consultation service.
  • The State of Minnesota ADI-SSS grant being implemented through 2017 delivers culturally infused Dementia-Capability training to the statewide network of aging services and health care providers via a Learning Management System that combines online and in-person training. Courses are tailored for the learner at three levels based on their prior knowledge, skills and job function. The Dementia-Capability training also addresses those with IDD and persons with dementia living alone. Cultural Consultants provide guidance and education to aging service providers and communities to increase understanding of the norms and values of diverse clients with dementia and their caregivers. Physician and care coordination training is delivered in collaboration with ACT Dementia-Capable Communities.

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West Virginia Coordinated Action, Response, Education and Support about Families Living with Dementia. The initiative's aim is to help organizations and individuals in non-profit, law enforcement, faith, business and other communities learn about dementia so they can assist and enhance the quality of life for individuals living with dementia. In addition, West Virginia Coordinated Action, Response, Education and Support (WV CARES) will connect individuals and families living with dementia to national, state and local resources for education and support. The Blanchette Rockefeller Neurosciences Institute is leading the effort along with key partners throughout the state including AARP, Alzheimer's Association-West Virginia Chapter, the Claude W. Benedum Foundation, the Manahan Group, the West Virginia Bureau of Senior Services, and the West Virginia Sheriff's Association.

Outcomes for Phase I of this initiative are: (1) educate West Virginians about the prevalence, early warning signs and symptoms of AD/ADRD, as well as the economic impact of the disease; (2) establish dementia-friendly faith communities that are a safe, supportive and welcoming environment for people with dementia; (3) establish dementia-friendly financial/legal services as legal and financial advisors may be the first to identify cognitive decline; (4) encourage dementia-friendly businesses that are meeting the needs of customers and employees; and (5) ensure dementia awareness among emergency response and law enforcement personnel.

WV CARES is part of the DFA network as the only statewide initiative of the network's six pilot sites.

For more information, see:

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Supported Decision Making Resource Center. ACL is promoting supported decision making (SDM) because it is a valuable option in helping people with dementia and others who may have cognitive issues exert control over choices made in their lives. SDM can also improve current guardianship arrangements for older adults and people with disabilities who need support. SDM is a more inclusive alternative than guardianship that uses trusted friends, family members and advocates to assist people with disabilities understand and make their own choices. SDM shows great promise for increasing self-determination and improving quality of life outcomes. ACL supports a national training, technical assistance, and resource center to explore and develop SDM as an alternative to guardianship. Among the center's projects is development of resources for professionals that include legal documents, standards for persons involved in SDM, research to discover how people use SDM, and evaluation of its effectiveness. The ultimate goal is to develop a model that will help states and individuals consider alternatives to guardianship by 2019.

For more information, see:

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Analysis of New Payment and Service Options for Medicare-Medicaid Dual Eligible Beneficiaries. ASPE is currently engaged in a project to produce targeted research briefs on options for expanding the Programs of All-Inclusive Care for the Elderly (PACE). PACE was established as a permanent Medicare and Medicaid benefit by the Balanced Budget Act of 1997, and it attempts to help nursing home eligible older adults avoid institutional care by providing them with an appropriate, tailored mix of coordinated acute care and HCBS. PACE is designed for the frail elderly. To be eligible, participants must be 55 or older and certified by their state of residence as being eligible for nursing home level of care. The PACE Innovation Act gives the Secretary of HHS the authority to test changes to the PACE model, such as serving individuals under the age of 55, and people who do not meet the current nursing home level of care criteria, but may be at-risk of entering a nursing home. The anticipated deliverables for this project include four research briefs that address the policy implications, benefit design, and financing structure of an expanded PACE program, including a descriptive analysis of subpopulations of dual eligible beneficiaries under age 55. Nationally, nearly half (49% comp) of PACE participants have been diagnosed with dementia, therefore lessons from the PACE model may have strong applicability to the field of dementia care broadly. Reports are expected by December 2017.

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Resources for Enhancing Alzheimer's Caregivers Health VA. As part of the VA's Caregiver Support Program, the Memphis Caregiver Center has been training staff since 2011 to deliver the REACH-VA caregiver program. Over 1,000 VA staff have been trained. In 2017, through a partnership between VA's Office of Care Management and Social Services and Office of Rural Health, REACH-VA is offered directly from Memphis to caregivers of veterans and veterans who are caregivers. A recent article reported that after caregiver participation in REACH-VA, caregivers are better able to manage the behavioral concerns of the person with dementia and their own stress and burden; in addition, health care costs for the person with dementia are decreased.

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VA Models of Non-institutional Long-Term Care. VHA has implemented innovative programs to provide patient-centered alternatives to long-term institutional care. New models of care have included programs focusing on dementia care, care coordination, and/or caregiver support. A summary report on Veterans Health Administration (VHA) Innovative Dementia Models of Care: Patient-Centered Alternatives to Institutional Extended Care was posted online. The report described a number of innovative programs developed and implemented at VA medical facilities, along with some initial results and lessons learned from the projects.

VHA continues to offer a range of innovative dementia care programs in urban, suburban and rural areas that provide veteran and caregiver support through multi-media communication, education, in home services, outpatient services, and interaction with primary care teams.

Examples of some of these sustained, successful innovative programs include the following:

  • The Caring for Older Adults and Caregivers at Home program is a home-based dementia care program that assists veterans and their caregivers through support, education, and referrals with the aim of delaying nursing home placement, reducing caregiver burden, and improving dementia care. The program has been recognized by VA's Office of Rural Health as a Promising Practice based on improved access, strong partnerships/working relationships, evidence of clinical impact, return on investment, operational feasibility, and customer satisfaction.
  • The VA Mobile Adult Day Health Care (ADHC) program, also known as the ADHC Mobile Veteran Program, is a therapeutically-oriented outpatient program that serves to enhance veterans' quality of life and alleviate isolation and depression by maximizing their physical, mental, and social abilities and well-being. The program provides support and respite care for families and other caregivers of veterans who are functionally impaired and/or socially isolated, enabling the veteran to maintain residence in a supportive home environment. VHA establishes community partnerships, usually with Veteran Service Organizations, that donate the use of their site. VHA staff travel to the site during specified days, as agreed upon with the community partner. veterans must have a designated VA primary health care provider who provides orders while the veteran is enrolled in the program. The VA Mobile ADHC program treatment team recommendations are communicated to the primary health care provider based on the veteran's individual need.

     

For more information, see:

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VA Care of Patients with Complex Problems. VA is working to identify promising care models for veterans with complex medical, neurocognitive, and psychiatric comorbidities with behaviors that can be disruptive to safe and effective care across inpatient and nursing home care settings. Many of these veterans have dementia. Preliminary focus is on interdisciplinary behavioral consultation models and transitional care models to facilitate discharge to appropriate levels of care and decrease behavioral readmissions.

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Medicare-Medicaid Accountable Care Organization Model. CMS announced a new model that builds on the Medicare Shared Savings Program, where Medicare Accountable Care Organizations (ACOs) that hit spending and quality targets are able to share in savings with CMS. This particular model will consider Medicaid savings, as the enrollees will be dually eligible for Medicare and Medicaid, and could include long-term care services. CMS intends to enter agreements with as many as six states.

For more information, see:

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Research Continues to Seek New and Effective Ways to Improve Care. An overwhelming majority of older adults want to continue living at home as they age. In recognition, the Collaborative Aging (in Place) Research using Technology (CART) Initiative unites NIH, other government agencies, academic, and industry experts to develop and test tools that track changes in older adults' health status and activities unobtrusively in real time, so they can remain at home as long as possible. Launched in October 2016, the $9 million, 4-year project, which includes contributions from a number of NIH institutes and VA, will start with a pilot project in more than 200 homes in rural and urban communities across the United States. The potential benefits for older adults and their families and/or caregivers are many as more people could stay in their own homes as they age, comfortably and safely.

For more information, see:

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Translation of Care of Persons with Dementia in their Environments in a Publicly-Funded Home Care Program. This home-based intervention involves up to 12 home visits; a nurse provides education to caregivers as to common concerns (constipation, detection of pain, incontinence, hydration and importance of taking care of self), conducts a brown bag medication review, takes blood and urine from the person with dementia and does a visual inspection of skin integrity; an occupational therapist meets with families to assess abilities of person with dementia and to work with caregiver to provide strategies for managing their care challenges and educate them as to the nature of the disease and ways to support daily functioning.

Activities include:

  • NIA-funded trial ongoing in Connecticut to translate this approach in Medicaid Waiver Program (Principal Investigator, Dr. Richard Fortinsky, Co-Investigator, Dr. Laura Gitlin).
  • ACL-funded project to Maine's Adult Day Serves to integrate Adult Day Plus and Care of Persons with Dementia in their Environments (COPE) Intervention.
  • ACL-funded project to Orange County, North Carolina to integrate COPE/Tailoring Activities for Persons with Dementia and Caregivers (TAP) into home care services.
  • Australia-funded translational study of COPE in various settings (hospital to home, home care, social service agencies).
  • COPE as part of the MIND model being tested under the CMS's (Innovation Center) Health Care Innovation Awards (HCIAs).
  • COPE being integrated into a program for Managed Care to be delivered by Volunteers of America.

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Patterns of Care and Home Health Utilization for Community-Admitted Medicare Patients. The Medicare home health payment policy for fee-for-service (FFS) has undergone several changes in the past decades. There have also been overall increases in Medicare home health utilization. Growth in utilization has been particularly strong for community-admitted users (those individuals for whom home health episodes are not preceded by a hospitalization or post-acute care (PAC) stay). MedPAC has suggested that this is indicative of the fact that some beneficiaries may be using the home health benefit as a long-term care benefit.14 Several alternative explanations for the growth of the community-admitted users are plausible. Indeed, a recent Academy Health meeting on PAC noted that as the American population ages, those with chronic conditions will likely cycle between post-acute and chronic care services.15 ASPE has begun a study to better understand the growth in use of the Medicare home health benefit by community-admitted users. This research will focus on detailed beneficiary characteristics and the trajectory of care of the community-admitted users to clarify the source of the growth in the benefit for this group of beneficiaries using home health, identify possible gaps in care or inefficient use of services, and inform benefit design. A report will be available later in 2017.

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