Building a Care Ecosystem
The Care Ecosystem model was designed to help address the unmet needs of persons with dementia and their caregivers.

What is the Care Ecosystem?

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 and web-based intervention was developed and studied across California, Nebraska and Iowa via an award from the Center for Medicare and Medicaid Innovation (CMMI grant number 1C1CMS331346) from 2014–2018 and funding from the National Institute for Health (NIH/NIA grant number R01 AG056715) from 2017–2022. The Care Ecosystem is currently being tested in a pragmatic clinical trial across six health systems (NIH/NIA grant number R01 AG074710-01 from 2022–2024).

The Care Ecosystem model includes:

  • Care team navigators (CTNs)
  • Clinicians with dementia expertise (nurse, pharmacist, social worker)
  • Care protocols
  • Curated information and resources

The CTN is the main point of contact for patients and caregivers in the Care Ecosystem. They are unlicensed yet trained to screen for dementia-related needs and provide support and information. Their work is guided by care protocols and they are supported and supervised by a clinician (nurse or social worker).

The Care Ecosystem improves the quality of life for people with dementia and their caregivers and reduces emergency department use.

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The Care Ecosystem lowers potentially inappropriate medication use and polypharmacy.

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The Care Ecosystem lowers Medicare costs.

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Caregiver Testimonial Videos


Locations of Active Care Ecosystem Programs

Please note that some locations have more than one active program.

Locations of Active Care Ecosystem Programs in the USA

Who is the Care Ecosystem for?

The Care Ecosystem was designed to enable health systems, clinics and community organizations to provide dementia-capable care to the growing population affected by dementia and their caregivers.

The Care Ecosystem Toolkit includes:

This toolkit provides an overview of the Care Ecosystem model and how to implement it in your institution.


Download the Toolkit

How Can the Care Ecosystem Toolkit be Used?

The Care Ecosystem materials are protected under a Creative Commons license that requires attribution whenever they are used. Materials may be copied, redistributed and adapted. However, appropriate credit must be given as follows: any publications or public presentations stemming from the use of the Care Ecosystem model or materials must credit the Care Ecosystem as appropriate. For example, if an adapted version of the Care Ecosystem care model and materials is deployed, any public presentation or publication about the care provided should note the use of Care Ecosystem materials. In addition, all Care Ecosystem materials used without modifications should be branded or co-branded “Care Ecosystem,” or should have a footnote that reads “Used with permission from the Care Ecosystem,” Any materials with modifications should have a footnote that reads “Adapted from the Care Ecosystem,”

There is no charge for using the Care Ecosystem materials; however, we reserve the right to identify organizations that use Care Ecosystem materials in public-facing content. For more information, please email [email protected].

Care Ecosystem Implementation Projects

The Milken Institute reports on opportunities and challenges to pay for the Care Ecosystem

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Making the Business Case for Value-Based Dementia Care

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Health Affairs reports on implementing the Care Ecosystem

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Care Ecosystem Scientific Publications

  1. Guterman EL, Kiekhofer RE, Wood AJ, Allen IE, Kahn JG, Dulaney S, Merrilees JJ, Lee K, Chiong W, Bonasera SJ, Braley TL, Hunt LJ, Harrison KL, Miller BL, Possin KL. Care Ecosystem Collaborative Model and Health Care Costs in Medicare Beneficiaries With Dementia: A Secondary Analysis of a Randomized Clinical Trial. JAMA Intern Med. 2023:e234764. doi: 10.1001/jamainternmed.2023.4764.
  2. Rosenbloom MH, Kashyap B, Diaz-Ochoa A, Karrmann J, Svitak A, Finstad J, Brombach A, Sprandel A, Hanson L, Dulaney S, Possin K. Implementation and review of the care ecosystem in an integrated healthcare system. BMC Geriatr. 2023;23:515. doi: 10.1186/s12877-023-04146-z.
  3. Sideman AB, Merrilees J, Dulaney S, Kiekhofer R, Braley T, Lee K, Chiong W, Miller B, Bonasera SJ, Possin KL. "Out of the clear blue sky she tells me she loves me": Connection experiences between caregivers and people with dementia. J Am Geriatr Soc. 2023;71:2172-2183. doi: 10.1111/jgs.18297
  4. Liu AK, Possin KL, Cook KM, Lynch S, Dulaney S, Merrilees JJ, Braley T, Kiekhofer RE, Bonasera SJ, Allen IE, Chiong W, Clark AM, Feuer J, Ewalt J, Guterman EL, Gearhart R, Miller BL, Lee KP. Effect of collaborative dementia care on potentially inappropriate medication use: Outcomes from the Care Ecosystem randomized clinical trial. Alzheimers Dement. 2022. doi: 10.1002/alz.12808.
  5. Brungardt A, Cassidy J, LaRoche A, Dulaney S, Sawyer RJ, Possin KL, Lum HD. End-of-Life Experiences Within a Dementia Support Program During COVID-19: Context and Circumstances Surrounding Death During the Pandemic. Am J Hosp Palliat Care. 2022:10499091221116140. doi: 10.1177/10499091221116140.
  6. Merrilees J, Robinson-Teran J, Allawala M, Dulaney S, Rosenbloom M, Lum HD, Sawyer RJ, Possin KL, Bernstein Sideman A. Responding to the Needs of Persons Living With Dementia and Their Caregivers During the COVID-19 Pandemic: Lessons From the Care Ecosystem. Innov Aging. 2022;6:igac007. doi: 10.1093/geroni/igac007.
  7. Manivannan M, Heunis J, Hooper SM, Bernstein Sideman A, Lui KP, Braley TL, Possin KL, Chiong W. Use of Telephone- and Internet-Based Support to Elicit and Address Financial Abuse and Mismanagement in Dementia: Experiences from the Care Ecosystem Study. J Alzheimers Dis. 2022;86:219-229. doi: 10.3233/JAD-215284.
  8. Ma H, Kiekhofer RE, Hooper SM, Dulaney S, Possin KL, Chiong W. Goals of Care Conversations and Subsequent Advance Care Planning Outcomes for People with Dementia. J Alzheimers Dis. 2021;83:1767-1773. doi: 10.3233/JAD-210720.
  9. Possin KL, Merrilees JJ, Dulaney S, Bonasera SJ, Chiong W, Lee K, Hooper SM, Allen IE, Braley T, Bernstein A, Rosa TD, Harrison K, Begert-Hellings H, Kornak J, Kahn JG, Naasan G, Lanata S, Clark AM, Chodos A, Gearhart R, Ritchie C, Miller BL. Effect of Collaborative Dementia Care via Telephone and Internet on Quality of Life, Caregiver Well-being, and Health Care Use: The Care Ecosystem Randomized Clinical Trial. JAMA Intern Med. 2019;179:1658-1667. doi: 10.1001/jamainternmed.2019.4101.
  10. Bernstein A, Harrison KL, Dulaney S, Merrilees J, Bowhay A, Heunis J, Choi J, Feuer JE, Clark AM, Chiong W, Lee K, Braley TL, Bonasera SJ, Ritchie C, Dohan D, Miller BL, Possin KL. The Role of Care Navigators Working with People with Dementia and Their Caregivers. J Alzheimers Dis. 2019;71:45-55. doi: 10.3233/JAD-180957.
  11. Rosa TD, Possin KL, Bernstein A, Merrilees J, Dulaney S, Matuoka J, Lee KP, Chiong W, Bonasera SJ, Harrison KL, Kahn JG. Variations in Costs of a Collaborative Care Model for Dementia. J Am Geriatr Soc. 2019;67:2628-2633. doi: 10.1111/jgs.16076.
  12. Guterman EL, Allen IE, Josephson SA, Merrilees JJ, Dulaney S, Chiong W, Lee K, Bonasera SJ, Miller BL, Possin KL. Association Between Caregiver Depression and Emergency Department Use Among Patients With Dementia. JAMA Neurol. 2019;76:1166-1173. doi: 10.1001/jamaneurol.2019.1820.
  13. Chen Y, Wilson L, Kornak J, Dudley RA, Merrilees J, Bonasera SJ, Byrne CM, Lee K, Chiong W, Miller BL, Possin KL. The costs of dementia subtypes to California Medicare fee-for-service, 2015. Alzheimers Dement. 2019;15:899–906. doi: 10.1016/j.jalz.2019.03.015.
  14. Bernstein A, Rogers KM, Possin KL, Steele NZR, Ritchie CS, Miller BL, Rankin KP. Primary Care Provider Attitudes and Practices Evaluating and Managing Patients with Neurocognitive Disorders. J Gen Intern Med. 2019;34:1691–1692. doi: 10.1007/s11606-019-05013-7.
  15. Merrilees JJ, Bernstein A, Dulaney S, Heunis J, Walker R, Rah E, Choi J, Gawlas K, Carroll S, Ong P, Feuer J, Braley T, Clark AM, Lee K, Chiong W, Bonasera SJ, Miller BL, Possin KL. The Care Ecosystem: Promoting self-efficacy among dementia family caregivers. Dementia (London). 2018:1471301218814121. doi: 10.1177/1471301218814121.
  16. Possin KL, Merrilees J, Bonasera SJ, Bernstein A, Chiong W, Lee K, Wilson L, Hooper SM, Dulaney S, Braley T, Laohavanich S, Feuer JE, Clark AM, Schaffer MW, Schenk AK, Heunis J, Ong P, Cook KM, Bowhay AD, Gearhart R, Chodos A, Naasan G, Bindman AB, Dohan D, Ritchie C, Miller BL. Development of an adaptive, personalized, and scalable dementia care program: Early findings from the Care Ecosystem. PLoS Med. 2017;14:e1002260. doi: 10.1371/journal.pmed.1002260. PubMed Central PMCID: PMC5360211.

Resources for Evaluating Dementia Care Models