Care Ecosystem

The Care Ecosystem was first implemented at the University of California, San Francisco (UCSF) Edward and Pearl Fein Memory and Aging Center and the University of Nebraska Medical Center (UNMC) as part of a randomized controlled trial, in which 780 person-with-dementia-caregiver dyads enrolled. The care model and early findings are described in this PLOS Medicine article, and the results based on one year of enrollment have been published in JAMA Internal Medicine. For the trial, the Care Ecosystem was delivered from the two hubs to participants located throughout the states of California, Nebraska and Iowa in English, Spanish and Cantonese. Study participants were not required to receive their medical care from UCSF or UNMC. In subsequent implementation projects, the Care Ecosystem has been integrated with the clinic or health system in which the person with dementia receives their medical care.

The relationship between a Care Team Navigator (CTN) and the dyad is a core component of the Care Ecosystem. The CTN responds to dyads’ needs and reaches out proactively to provide support and education and help with reviewing medications, promoting safety and quality of life, planning for medical, financial, and legal decisions, and managing behaviors. Care is tailored to the needs and preferences of each dyad. Issues that exceed the CTN’s scope are triaged by the specialist team.

UCSF Team

• Kate Possin, PhD, Care Ecosystem Program Director at UCSF
• Sarah Dulaney, RN, CNS, Clinical Director and Nurse Supervisor
• Jennifer Merrilees, RN, PhD, Director of Caregiver Support
• Winston Chiong, MD, PhD, Director of Decision Making
• Sarah Hooper, JD, Director of Legal Decision Making
• Kirby Lee, PharmD, Medications Director
• Shalini Lynch, PharmD, Clinical Pharmacist

The mission of the UCSF Edward and Pearl Fein Memory and Aging Center is to provide the highest quality of care for individuals with cognitive problems, to conduct research on causes and cures for degenerative brain diseases, and to educate health professionals, patients, and their families.

The Fein Memory and Aging Center Clinic provides specialized diagnostic evaluations and treatment recommendations for common and rare types of neurodegenerative diseases. With grant funding from the Administration for Community Living (ACL) and the National Institute on Aging, a Care Team Navigator (CTN) trained to implement the Care Ecosystem, is integrated with the MAC’s multidisciplinary clinical team (neurologists, social workers, and nurses) to deliver telephone-based support, education, care planning, and coordination. Clinic providers refer patient and caregiver dyads who meet program eligibility criteria to the CTN for an extra layer of support and follow-up. The CTN works with patients across all stages of dementia living throughout the state of California who receive ongoing care from a provider at UCSF Health. Care Ecosystem implementation is aligned with proposed Medicare payment models for dementia; and care planning and chronic care billing mechanisms; however, institutional barriers have limited progress toward implementing these mechanisms.

Care Ecosystem Program Director at the Fein MAC Clinic: Sarah Dulaney, RN, CNS

The Curry Senior Center is a safety-net clinic dedicated to providing comprehensive primary care and support services to marginalized low-income and homeless seniors in the Tenderloin neighborhood of San Francisco. Most patients are socially isolated and do not have informal caregivers, and many have limited English proficiency. Curry offers home visits for patients with limited mobility, congregate meals and activities, case management, and behavioral health services for support with housing, smoking cessation, substance abuse, and mental health.

With funding from the Administration for Community Living (ACL), a Care Team Navigator (CTN) trained to implement the Care Ecosystem was integrated with Curry’s multidisciplinary team to deliver care onsite. Providers referred patients to the CTN for dementia risk screens (measuring cognition, depression, function, safety, advance care planning, and unmet needs). The CTN then worked with patients, their providers, and others involved in the patient’s care to address identified issues and connect patients with local community resources. The Care Ecosystem CTN at Curry typically served patients with mild cognitive impairment to early-stage dementia and often acted as a bridge to more intense case management services or long-term placement.

The Curry Senior Center continued patient navigation services for patients with co-morbid mental illness. The patient navigator screens for and addresses unmet needs under the guidance and supervision of a mental health case manager and nurse practitioner.

Care Ecosystem Program Lead at Curry: Sarah Dulaney, RN, CNS
Curry Senior Center Provider: Anna Kuo, RN, NP

The HealthPartners Center for Memory and Aging (HP-CMA) is a specialized clinic based in Saint Paul, Minnesota serving patients with dementia and their families. HP-CMA is part of the nonprofit HealthPartners managed care health system based in Bloomington, Minnesota. Their clinical services include a multidisciplinary team of neurologists, neuropsychologists, nursing staff, and social workers providing in-person diagnostic evaluations and treatment recommendations for Alzheimer’s disease and associated disorders.

With a 4-year grant from the Merck Foundation, HealthPartners implemented the Care Ecosystem with the aim to improve access to follow-up care and support for underserved rural-dwelling patients with dementia and their families. Care Team Navigators (CTNs) trained to implement Care Ecosystem were integrated with HealthPartners’ multidisciplinary team onsite to provide dementia care navigation. Providers referred high-needs patient and caregiver dyads to the CTN for an additional layer of care support and the CTN worked with the clinical team to address needs identified by the patient and caregiver. They provided support, education, monitoring, and links to community support services. HealthPartners continues to deliver the Care Ecosystem as part of a multi-site pragmatic trial led by UCSF.

You can read the results of their work here: 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.

Care Ecosystem Program Director at HealthPartners: Leah Hanson, PhD
Project Coordinator at HealthPartners: Ann Brombach

The UCHealth Seniors Clinic, located in the Denver, Colorado metro area, provides primary health care for patients 75 years and older. Seniors Clinic providers and staff work to promote wellness for older adults and to improve the diagnosis and treatment of age-related diseases and syndromes.

With funding from the Centers for Medicare and Medicaid Services Comprehensive Primary Care+ and Primary Care First programs, the Seniors Clinic has implemented the Care Ecosystem since September 2018, with a Care Team Navigator (CTN) embedded directly in the clinic. Patients and their caregivers are referred directly to the CTN for support by the patient’s primary care provider. The CTN performs a needs assessment, provides support and education, and connects patient-caregiver dyads to local community services as appropriate. The CTN works closely with providers and the rest of the interdisciplinary team at the clinic to address complex needs and issues, to improve follow-up care for patients with dementia and their caregivers.

Care Ecosystem Program Director: Hillary Lum, MD, PhD
Care Ecosystem Project Manager: Adreanne Brungardt, MM, MT-BC

The Los Angeles County Department of Health Services (DHS) is the second-largest municipal health system in the nation and provides integrated care for a diverse population in low-income communities across the region. Harbor-UCLA Medical Center is one of four DHS clinics that specializes in geriatric medicine and provides comprehensive team-based care for older adults with cognitive impairment. Many of the patients cared for within the DHS system are non-English speaking immigrants with poor health literacy and low socioeconomic status. Geriatric clinics throughout DHS have teams that vary in their make-up with varying disciplines and resources available depending on the DHS site. Additionally, there is currently no standardized program throughout DHS to support patients with dementia and their caregivers.
With a CTSI Implementation Science grant, the geriatrics clinic at Harbor-UCLA Medical Center adapted and piloted the Care Ecosystem in four DHS clinics in June 2020. Care Ecosystem protocols were adapted for DHS clinic workflows and the population they serve. Existing clinic staff at each site completed Care Ecosystem training and acted as dementia navigators, screening for dementia-related needs, providing information and support, and connecting families with community-based services. Navigators may initially meet patients and families during an in-person clinic visit and then provide ongoing telephone follow-up. The Harbor-UCLA Team is currently delivering the Care Ecosystem as part of a UCSF-led multi-site pragmatic trial.

Care Ecosystem Program Directors: Katie Ward, MD, and Mailee Hess, MD

Mass General Brigham is a non-profit, integrated health system that serves patients across a network of healthcare providers that includes the Brigham and Women’s Hospital and Massachusetts General Hospital in Boston. The Integrated Care Management Program (iCMP) at Mass General Brigham is a complex care management program embedded in primary care practices that provides team-based support and care coordination for the most medically complex and seriously ill patients. iCMP employs registered nurses, social workers, and community health workers to manage care for approximately 14,000 adult patients at Mass General Bringham with an expanding focus on serving older adults with dementia.

Working with the Impact Collaboratory, the Mass General Brigham team provided an adapted version of the Care Ecosystem training program to select iCMP case managers to enhance their dementia care skills. Leveraging the electronic medical record, Mass General Brigham evaluated the impact of this training on nurse care manager practice.

Care Ecosystem Pilot Investigators: Brent Forester, MD, Msc, and Christine Ritchie, MD, MSPH

In a collaborative effort to improve dementia care in their region, providers from the Providence Seniors Clinic and the Brain and Spine Institute in Portland, Oregon piloted the Care Ecosystem with funding from a private donor. Existing clinical staff completed Care Ecosystem training to become Care Team Navigators (CTNs), a specialist clinical team was identified, and protocols were adapted to accommodate workflows. Patients and their caregivers are referred to the program by their primary care provider or neurologist for an extra layer of education, support and care coordination. The CTN screens for dementia-related needs and works with their clinical team, the patient and caregiver, and the patient’s providers to address these needs. Care is delivered by phone and online. Care Ecosystem implementation at Providence Portland continues as part of a UCSF-led multi-site pragmatic trial with plans to expand recruitment from rural clinics.

Providence Portland Principal Investigator: Nicholas Olney, MD
Providence Portland Clinical Director: Mary Beth Kuebrich, RN, NP

Other sites using the Care Ecosystem model or materials:

• Sentara Health, Norfolk, Virginia
• Virginia Commonwealth, Richmond, Virginia
• Hospice of the Valley, Phoenix, Arizona
• OCCK, Inc., Salina, Kansas
• MaineHealth, Portland, Maine
• UT San Antonio Biggs Institute, San Antonio, Texas
• Dept of Aging State of California, Ventura, California (and Marin, Imperial, and Ventura Counties)
• Office of Alzheimer’s & Dementia Care
• New Mexico Aging and Long-Term Services Department, Sante Fe, New Mexico
• Memory Care Home Solutions, St. Louis, Michigan
• Alzheimer’s Orange County, Irvine, California
• Alzheimer’s Greater Los Angeles, Los Angeles, California
• Baystate Health, Springfield, Massachusetts