Study examines new payment model for dementia care

Can a dementia care coordination model delay or prevent the need to move someone with dementia from home to another setting, such as a nursing home or assisted living facility? A recent study tried to answer that question.

The 18-month pilot program brought resources and counselors to elderly Baltimore residents with dementia and other memory disorders—and it significantly increased the length of time they lived successfully at home, according to researchers from the Johns Hopkins University School of Medicine. Staying at home was a clear preference for most of those who participated in the study.

"The project demonstrated that we were able to help such people age in place without sacrificing their quality of life," says study leader Quincy Miles Samus, PhD, an assistant professor of psychiatry and behavioral sciences at the medical school, quoted in a medical school press release.

Health insurance does not always cover non-medical needs and coordinator services, and the study sought to demonstrate the financial savings and value of home- and community-based care in hopes that more medical insurers might cover the cost of programs like this one in the future.

The trial, known as Maximizing Independence (MIND) at Home, involved 303 people aged 70 or more years who had memory disorders, primarily dementia and mild cognitive impairment. One hundred and ten of them received an in-home visit from a memory care coordinator and nurse who assessed a range of care needs, including diagnosis of memory problems, review of medications, behavior problems, daily activities, and untreated medical problems such as hearing or vision problems, and hypertension or diabetes. The care team then developed a personalized care plan and worked with the family over time to oversee progress and attend to new needs that arose.

In a report published online in the American Journal of Geriatric Psychiatry, the investigators say that those who got 18 months of care coordination with home visits were able to safely stay in their homes a median of 288 extra days, or around 9.5 months, over a median follow-up period of about 2 years. "This can make a huge difference in terms of comfort, money and quality of life for those involved," Samus says.

The researchers also found that participants who met regularly with coordinators were significantly less likely to leave their homes or die than those in the control group (30 percent versus 45.6 percent). Additionally, the participants had fewer unmet care needs, particularly for safety and legal/advance care issues, and had improved quality of life.

In the trial, coordinators checked for home safety, nutrition and food availability and whether those with dementia participated in meaningful or purposeful activities beyond simply watching television for much of the day. They also assessed whether those with dementia should be evaluated for driving safety, whether they were at risk of wandering off and getting lost, and what local community resources were available to address unmet needs.

Beyond such services, the program provided education about dementia and memory problems to caregivers and those with dementia, as well as informal counseling and problem-solving. Legal issues such as advance directives and wills also were discussed, and coordinators contacted family members at least once a month. Home and personal safety issues affected 90 percent of the participants at the start of the trial, the researchers reported. Some 65 percent needed general medical care, 52 percent showed a lack of meaningful activities and 48 percent needed legal/advance care planning.

The memory care coordinators were community workers and did not have clinical backgrounds or prior training in caring for people with memory disorders, suggesting that the potential workforce that could acquire coordinator skills is large, Samus says. Coordinators received intensive training over four weeks, including lectures, role play and observation of people with dementia in clinical settings.

The care coordinators received hands-on support from a nurse and a physician, and the team met weekly to discuss cases.

The results suggest that wider application of the home care model should be evaluated in the future as well as whether it can provide a cost-benefit to public insurers such as Medicaid and Medicare, Samus says.

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