Care Ecosystem: Navigating Patients and Families through Stages of Care

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Read about our study in Spanish or Cantonese (PDF).

Summary

  • Study directors: Bruce Miller, MD; Kate Possin, PhD and Stephen Bonasera, MD
  • Sponsor: Centers for Medicare & Medicaid Services
  • Recruiting: Now–2017
  • Official study title: The UCSF and UNMC Dementia Care Ecosystem: Using Innovative Technologies to Personalize and Deliver Coordinated Dementia Care
  • Purpose: Most dementia care today is crisis-oriented, intermittent and impersonal. The Care Ecosystem is a proactive model that emphasizes coordinated, continuous, and personalized care and aims to improve health and satisfaction for patients and their caregivers. The intervention will also try to reduce avoidable emergency room visits and hospitalizations, and delay entry into a nursing home.

Do I Qualify?

For Patient Participation

  • Has a diagnosis of dementia
  • Has a primary caregiver
  • Is covered by Medicare or Medicaid or is Medi-pending
  • Speaks English, Spanish, or Cantonese
  • Lives in California, Nebraska, or Iowa
  • Is age 45 or older
  • Does not reside in a nursing home

For Caregiver Participation

  • Agrees to join the study
  • Speaks English, Spanish, or Cantonese

Overview

UCSF and the University of Nebraska Medical Center are partnering with patients and their caregivers to better understand and manage dementia with a new, telephone and web-based model of care. This project is funded by a 3-year, $10 million Health Care Innovations Award from the Centers for Medicare & Medicaid Services. The impact of the Care Ecosystem will be studied, as it aims to support patients and their caregivers with decision-making, medications, caregiver support, online education, and, for a subset of patients, remote monitoring with smartphones, watches, and home sensors.

What's Involved?

For all enrolled patients and caregivers, we will first conduct telephone surveys on their experience with dementia and dementia care. Two-thirds of participants will then be randomly selected to participate in Navigated Care. For these people, Care Team Navigators (CTNs) will provide support through an innovative dashboard that will drive personalized and coordinated care. The CTNs will be backed by a Navigated Care Team, made up of social workers, nurses and pharmacists with dementia expertise. This team will help caregivers cope with and plan for the many challenges that face adults managing dementia.

Goals of the Intervention

Care Ecosystem aims to assist caregivers with the following:

  • Improving methods for patient-caregiver communication
  • Managing problematic patient behaviors, such as passivity or anger
  • Reviewing medications to reduce potentially dangerous drug interactions
  • Planning ahead for important financial and medical decisions
  • Referring and linking with community resources, such as caregiver support groups
  • Making sure the patient sees their doctor(s) when necessary

Contact Information

Please contact Marite Carrasco at Marite.Carrasco@ucsf.edu or (415) 514-8707 for more information about this project.

February 10, 2016