Integration of evidence-based collaborative care management models such as the MIND at
Home Dementia Care Coordination Program within Primary Care (PC) aligns with the Centers
for Medicare and Medicaid Services (CMS) initiatives to provide advanced PC services to
an especially complex and costly patient group and aligns with AHRQ's team-based
Collaborative Care Model. This project will embed and test the feasibility of a novel
best practice-based approach, MIND at Home, within PC to enhance and elevate the role of
existing PC staff to Memory Care Coordinators (MCCs), increase PC access to
interdisciplinary collaborative care, and systematically combines the benefits of
clinic-based services with home-based assessment to support family-centered care planning
and implementation for PLWD and their care partners. Weekly virtual collaborative
learning sessions that include geriatric psychiatry consultants augment the PC care
team's work to support the development and mastery of dementia assessment and care
management skills and confidence at the PC sites. Our overarching goal is to test and
establish feasibility, acceptability, fidelity, and sample size/referral rate data for
MIND at Home in PC to prepare for a future multi-site embedded pragmatic trial.
Aim 1: Evaluate the feasibility and validity of eligible PLWD identification, referral,
and enrollment in a best practice-based dementia care coordination program (MIND at Home)
at 3 primary care clinics. Algorithms based on CMS's Chronic Care Warehouse definition of
Alzheimer's Disease (AD) or AD and Related Dementias (ADRD) will be deployed in each
respective clinic's electronic health record (EHR) to identify eligible PLWD and
standardized referral and enrollment protocols will be enacted. Referral, recruitment,
patient acceptance, and attrition rates will be calculated to assess the feasibility of
use of the algorithm and of the recruitment protocol. Health equity in recruitment and
enrollment will be assessed by comparing demographics (race/ethnicity) of program
enrollees with the background population e.g., clinic ADRD patient panel, and by
comparing enrollment of rural vs. suburban PC sites.
Aim 2: Evaluate the feasibility, acceptability, and fidelity of implementing MIND at Home
in 3 primary care clinics in 2 geographically and demographically diverse integrated
health systems. Using a pragmatic trial design, 150 community-residing PC patients with
an ADRD diagnosis will be enrolled, each for a 3-month period. Program enrollees will
receive office- plus home-based dementia care assessment, individualized care planning,
and implementation by an interdisciplinary PC-based team, supported by regular case-based
learning sessions. Implementation will be assessed by collecting a standard set of
delivery workflow process, clinical, and health care utilization metrics. The
investigators will assess feasibility through referral, enrollment, and retention rates,
number of MCC-dyad contacts, and clinic staff participation in weekly
tele-collaboratives. Fidelity will be assessed through tracking the completion of
intervention components and PC team self-evaluation. The investigators will survey clinic
staff on perceived program acceptability, usefulness, and challenges/unintended
consequences. Program implementation will be tailored to accommodate diverse dyads (PLWD
- care partner), which will be closely monitored and tracked.
Aim 3: Evaluate the feasibility of ascertainment of patient-level outcomes over time
using electronic health record (EHR) data. The primary outcome (hospital transfers
including admissions, ER visits, and observation stays without admissions), and secondary
outcomes (number of medications for enrolled patients) will be gathered using EHR data.
Accuracy of ascertainment will be tested through chart review. All clinical outcomes will
be collected as time-stamped events for each enrolled patient retrospectively for 3
months prior to enrollment, during enrollment (3 months), and 1-month post-enrollment
(total observation=7 months). All outcomes will be assessed by race, ethnicity, and
rurality of the PLWD.
Embedding a collaborative, best-practice-based approach such as MIND at Home into PC is a
potentially powerful strategy to organize care, improve quality, reduce costs, and
maximize the population-level benefit for PLWD. This proposal tests the feasibility of
implementing MIND at Home into PC in a racially, ethnically, and geographically diverse
PLWD population in order to prepare for a multisite embedded pragmatic clinical trial
(ePCT) to evaluate effectiveness, and eventually support broader dissemination and uptake
in PC.