P2‐526: the Care Ecosystem: Designing Workflow for a System of Navigated Care in Dementia
Year: 2018
Type: article
Abstract: Dementia is a neurodegenerative disease affecting millions. The Care Ecosystem is a model of dementia care designed to provide personalized, cost-efficient care for persons with dementia (PWD) and their caregivers. This telephone intervention is being studied across California, Nebraska, and Iowa via an award by the Center's for Medicare and Medicaid Services (CMS). The Care Ecosystem includes: the Care Team Navigator (CTN) – an unlicensed dementia care support worker, clinicians with dementia expertise, and workflow protocols. It is now being implemented at two clinic sites in San Francisco with funding from the Administration for Community Living (ACL). Understanding how the CTN role can be deployed in diverse settings and how workflow fits with new billing mechanisms is an important step in meeting the demands for dementia-capable care. This project describes the CTN role at two diverse clinical practice sites and how workflow aligns with current billing systems. One CTN was assigned to a neurology clinic at a tertiary academic institution (UCSF Memory and Aging Center—MAC). The second CTN took the role at a federally qualified health center (Curry Senior Center Clinic—CSCC) that provides primary care to low-income seniors the majority of whom live alone with no support from an informal caregiver. The CTNs receive referrals and are supported by clinical staff at their specific sites. During the first three months, the CTN at CSCC completed13 intake assessments and the CTN at the MAC clinic completed 10. The CTNs discussed patient/caregiver-identified needs and goals, reviewed medications and advance care planning, administered neuropsychological, functional, and safety screens, and caregiver well-being assessments. None of patients at CSCC had caregivers and all at MAC had friend or family caregivers. The MAC CTN adjusted the intake process to be completed over a 3-month period, as caregivers were too overwhelmed with immediate needs. Comprehensive care plans are reviewed with supervising clinicians and routed to providers. Care plans met most criteria for the Cognitive Evaluation and Care Planning Medicare billing code (G0505). The Care Ecosystem shows promise as a feasible model for managing the challenges in providing care to PWD and their caregivers.
Source: Alzheimer s & Dementia
Language: English
Subfield: Psychiatry and Mental health
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2898064365