- Study directors: Bruce Miller, MD; Kate Possin, PhD and Stephen Bonasera, MD, PhD
- Sponsor: Centers for Medicare & Medicaid Services
- Recruiting: Ended February 2017
- Official study title: The UCSF and UNMC Dementia Care Ecosystem: Using Innovative Technologies to Personalize and Deliver Coordinated Dementia Care
- Purpose: Most dementia care today is crisis-oriented, intermittent and impersonal. The Care Ecosystem is a proactive model that emphasizes coordinated, continuous, and personalized care and aims to improve health and satisfaction for patients and their caregivers. The intervention will also try to reduce avoidable emergency room visits and hospitalizations, and delay entry into a nursing home.
Who is Eligible for This Study?
For Patient Participation
- Has a diagnosis of dementia
- Has a primary caregiver
- Is covered by Medicare or Medicaid or is Medi-pending
- Speaks English, Spanish, or Cantonese
- Lives in California, Nebraska, or Iowa
- Is age 45 or older
- Does not reside in a nursing home
For Caregiver Participation
- Agrees to join the study
- Speaks English, Spanish, or Cantonese (Spanish and Cantonese-speaking caregivers who do not also speak English can enroll starting in 2016)
The University of Nebraska Medical Center and the University of California San Francisco are partnering with patients and their caregivers to better understand and manage dementia with a new, telephone and web-based model of care. This project is funded by a 3-year, $10 million Healthcare Innovations Award from the Centers for Medicare & Medicaid. The impact of the Care Ecosystem will be studied, as it aims to support patients and their caregivers with decision-making, medications, caregiver support, online education, and, for a subset of patients, remote monitoring with smartphones, watches, and home sensors.
For all enrolled patients and caregivers, we will first conduct telephone surveys on their experience with dementia and dementia care. Two-thirds of participants will then be randomly selected to participate in Navigated Care. For these people, Care Team Navigators (CTNs) will provide support through an innovative dashboard that will drive personalized and coordinated care. The CTNs will be backed by a Navigated Care Team, made up of social workers, nurses and pharmacists with dementia expertise. This team will help caregivers cope with and plan for the many challenges that face adults managing dementia.
Goals of the Intervention
Care Ecosystem aims to assist caregivers with the following:
- Improving methods for patient-caregiver communication
- Managing problematic patient behaviors, such as passivity or anger
- Reviewing medications to reduce potentially dangerous drug interactions
- Planning ahead for important financial and medical decisions
- Referring and linking with community resources, such as caregiver support groups
- Making sure the patient sees their doctor(s) when necessary
The Care Ecosystem study is supported by Grant Number 1C1CMS331346 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services to help improve dementia care for patients and their caregivers. The content of this webpage is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
UNMC IRB Protocol #: 483-14-EP