Care EcoSystem: Ochsner Health System

Ochsner Health System290 enrolled

Overview

1. To determine the feasibility and acceptability of the Care Ecosystem program in the Ochsner clinical setting. 2. To assess the effect of the Care Ecosystem program on health care cost and quality care quality as measured by primary outcome variables. * Adapted from the Care Ecosystem, memory.ucsf.edu/Care-Ecosystem

Study Type

OBSERVATIONAL

Enrollment

290

Conditions

Dementia

Interventions

Care EcoSystemBEHAVIORAL

This is a care management program and health care outcomes feasibility study utilizing the dementia Care Ecosystem (CE) program developed at UCSF and tailored to high need Ochsner PWD (patient with dementia) and their CGs (caregivers). Dyads (CGs and PWD) will receive a tailored clinical assessment addressing dementia severity, PWD and CG needs, education/strategies to management common dementia issues, medical issues and medication reconciliation, caregiver wellness strategies, linkages to community-based resources, advance care planning, education about the risk of ED and hospitalization, and care coordination with other specialties. Dyads will be followed on a monthly basis to monitor needs, provide support, and problem solve issues.

Eligibility

Sex: ALLMin age: 55 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Male or female ≥55 years of age at baseline * Probable dementia diagnosis as evidenced by one or more of the following criteria: * Dementia listed on medical record problem list as of January 1, 2015 or later, or, in the opinion of the referring provider has dementia * Prescribed with any of the following: donepezil, memantine, galantamine HBR, rivastigmine, or tartrate; or, in the opinion of the referring provider, could take such medication * Lives in community Exclusion Criteria: * Documented history of Multiple Sclerosis, ALS, Traumatic Brain Injury, Huntington's Disease, Schizophrenia, Bipolar Disorder, or current Substance Abuse Disorder * Lives in a nursing home or assisted living facility * Unable to complete monthly telehealth or phone visits

Locations (1)

Ochsner Health System

New Orleans, Louisiana, United States