Collaborative Care Coordination Program for Alzheimer's Disease and Related Dementias

Harvard Pilgrim Health Care2,160 enrolled

Overview

This is a randomized, pragmatic clinical trial to evaluate the effectiveness of a collaborative care-coordination program embedded in a health plan for people living with Alzheimer's disease and related dementias (ADRD) and their care partners versus usual care. The study population will include community-dwelling Medicare Advantage members living with ADRD and their care partners. Outcomes will be healthcare utilization outcomes of individuals with ADRD and include emergency department visits, outpatient visits, avoidable emergency department visits, and admission to long-term care facilities.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

SUPPORTIVE_CARE

Masking

NONE

Enrollment

2,160

Conditions

Alzheimer's Disease and Related Dementias (ADRD)

Interventions

The Dementia Care Consultation program uses a telephone-based intervention to provide an in-depth, personalized service for individuals living with ADRD and their care partners. It consists of comprehensive needs assessments, creation and implementation of personalized care plans, monitoring and revising care plans, disease education and support coaching, referrals to community-based organizations for service and support, and access to assistance.

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

Community-dwelling Tufts Health Plan Medicare Advantage members with ADRD and their caregivers will be selected to participate in the trial based on the following inclusion/exclusion criteria: Inclusion Criteria (for members with ADRD) * Member of Tufts Health Plan Medicare Advantage plan * Medical and pharmacy insurance coverage in at least the prior 12 months * Have ≥1 ICD-10-CM diagnosis code for ADRD or dispensing for pharmacological treatment for ADRD in the prior 12 months Exclusion Criteria (for members with ADRD): * Reside in a nursing home or skilled nursing facility * Enrolled in a hospice program * Receiving or have received the Dementia Care Consultation program as part of the existing program at the time of enrollment Inclusion Criteria (for caregivers) * Age 18 years or older * Assume primary responsibility for members

Outcomes

Primary Outcomes

All-cause emergency department visits

Number of all-cause emergency department visits per member living with ADRD over the 12-month follow-up period.

Time frame: by 12 months

All-cause emergency department visits

Number of all-cause emergency department visits per member living with ADRD over the 6-month follow-up period.

Time frame: by 6 months

Secondary Outcomes

Outpatient visits

Number of outpatient visits per member living with ADRD over the 12-month follow-up period.

Time frame: by 12 months

Outpatient visits

Number of outpatient visits per member living with ADRD over the 6-month follow-up period.

Time frame: by 6 months

Avoidable emergency department visits

Number avoidable emergency department visits (defined using the validated New York University ED visit algorithm) per member living with ADRD over the 12-month follow-up period.

Time frame: by 12 months

Avoidable emergency department visits

Number avoidable emergency department visits (defined using the validated New York University ED visit algorithm) per member living with ADRD over the 6-month follow-up period.

Time frame: by 6 months

Admission to long-term care facilities

Number of members living with ADRD with the first admission to long-term care facilities over the 12-month follow-up period.

Time frame: by 12 months

Admission to long-term care facilities

Number of members living with ADRD with the first admission to long-term care facilities over the 6-month follow-up period.

Time frame: by 6 months

Collaborative Care Coordination Program for Alzheimer's Disease and Related Dementias

Overview

Conditions

Interventions

Eligibility

Locations (1)

Outcomes

Primary Outcomes

Secondary Outcomes