Fellowship Year 2016-2017
Dementia is the sixth leading cause of death in the United States and ranks fifth among individuals 65 years of age and older. Despite encouraging evidence showing a decline in dementia prevalence, adults aged 65 years and older are expected to represent 20% of the U.S. population by 2030. Given that age is the greatest risk factor for dementia, the prevalence of dementia is also expected to increase to 8.4 million by 2030. Alzheimer’s disease (AD), the most common form of dementia in the U.S., results in $236 billion in direct health care and long-term care costs. While increasing evidence demonstrates the clinical value of interventions aimed at modifiable risk factors associated with AD, the most significant costs for individuals with AD are long-term care, inpatient medical care, and outpatient medical care.
Using a method incorporating medical evidence, site visits, and expert interviews, we designed a composite care model that targets the major cost drivers for persons with dementia (PWD) and improves health care value within 1–3 years after implementation. The high value care model is comprised of the following components: 1) reduction of outpatient medical care costs through tailored chronic care 2) improved efficiency and resiliency of caregivers and 3) provision of cognitively protective acute medical care. Our care model also includes recommendations for a streamlined diagnostic process that can reliably diagnose patients with dementia in a primary care doctors office with minimal training and time.
Tailored Chronic Care
Our chronic care model includes evidence-based guidelines for primary care providers (PCPs) and care coordination for PWD delivered through a multidisciplinary dementia care team. Recommendations for PCPs include - rethinking routine cancer screening, discouraging placement of percutaneous feeding tubes, promoting advanced care planning discussions, and reducing the intensity of disease management for chronic conditions such as diabetes, hypertension, or chronic kidney disease.
Once identified, PWD are flagged in the health care system and supported by a multidisciplinary dementia care team that works closely with the patient’s primary care doctor. Our dementia care team adapts prior iterations of complex care management programs and includes a geriatric NP or MD, a pharmacist, social worker, and RN, and held together by care navigators who act as the primary point person for the patient and family.
Timely Caregiver Support
The harsh and relentless nature of care for PWD takes a toll on caregivers, and as caregiver burden increases, PWD often end up in the emergency department, re-hospitalized, and ultimately placed into long-term care at significant cost to patients, families, and health care insurers. Improving caregiving efficiency at the initiation of a caregiving role holds unique potential for reducing the number of unpaid caregiving hours required. Well-timed caregiver support using home-based interventions led by occupational therapists can stabilize functional abilities in care recipients and reduce the number of hours of caregiving required. Similarly, psychosocial interventions aimed at reducing caregiver burden can remediate depressive symptoms in caregivers, delay long-term placement, and reduce health care utilization of both caregivers and care recipients.
Cognitively Protective Acute Care
This arm of the model is built around the primary objective of reducing delirium, which leads to an acceleration of cognitive and functional decline that is often irreversible in patients with dementia. Our care model recommends alternatives to acute hospitalizations whenever possible through use of hospital at home when feasible. For those unable to be cared for through a hospital at home program due to medical or geographic constraints, we recommend the use of inpatient delirium prevention programs as a standard of care. One evidence-based protocol is the Hospital Elder Life Program (HELP) which has demonstrated reductions in delirium, improved quality outcomes, and significant cost savings to health systems and insurers. For those patients with dementia undergoing elective hospitalization for surgeries, we recommend perioperative prehabilitation with the goal of optimizing physiologic parameters prior to surgery.
Overall, the proposed high value dementia care model could lower the cost of health care for PWD in the United States by $42.6 billion within two years after implementation (including the costs of implementation and operation), representing total per member per year (PMPY) savings of 15.6%. Medicare only PMPY savings is estimated at 12.7% and long-term services and support and out of pocket PMPY savings is estimated at 18.3%. Additional savings of approximately $1 billion could be realized from reduction of unpaid caregiving hours required by caregivers.
Nicholas Bott, PsyD, Daniel Yang, MD, Clifford Sheckter, MD, Terry Platchek MD, Arnold Milstein, MD, MPH