Best Practices: Building better supports for dementia

Dr. James Pratty had grown increasingly frustrated with the fragmented care and inadequate support dementia patients and their caregivers were receiving.

“We saw patients who were suffering from confusion, delusions and falls,” said Pratty, senior medical officer for behavioral health and psychiatry at CareMore, a Medicare Advantage plan headquartered in Cerritos, Calif., that is owned by Anthem. “It was clear to us that a 30- to 45-minute visit was not enough time to educate the family and do the necessary interventions.”

Roughly 5.3 million Americans have Alzheimer's disease and that number is expected to jump to 7.1 million by 2025, according to the Alzheimer's Association. Costs associated with Alzheimer's are expected to balloon from $226 billion this year to as high as $1.1 trillion in 2050, the group predicts.

Providers, insurers and researchers are seeking innovative ways to better manage the complex behavioral and physical symptoms of dementia and provide the right patient and family supports, said Beth Kallmyer, vice president of constituent services at the Alzheimer's Association.

For CareMore, whose average member is 72 to 74 years old, the issue was especially pressing, Pratty said. In 2011, he and his colleagues decided to conduct a pilot project aimed at improving outcomes for dementia patients. But first they took a closer look at the care dementia patients were receiving. They found high rates of falls, high numbers of emergency department visits, high rates of hospital admissions, poor medication adherence, and poor patient and caregiver understanding of the illness.

“Their doctors are our aligned primary-care providers, and they're good doctors but they don't have the time to really explain things,” Pratty said.

He and his team identified a group of 46 dementia patients for the pilot program, called the Brain Health Program. It was based on CareMore's successful disease-management programs, which use a multidisciplinary approach to coordinate care for patients with chronic obstructive pulmonary disease, congestive heart failure, end-stage renal disease and other conditions.

The Brain Health team included a neuropsychologist, psychiatrist, neurologist, pharmacist, case manager, dietician, nurse practitioner and licensed clinical social worker who did home evaluations for health risks such as loose rugs and proximity to busy streets. The team followed the 46 patients closely for six months. They also educated patients and caregivers with a series of short lectures about falls, nutrition, hydration, safety, medication issues and behavior management and legal issues such as advanced directives.

Then they compared the patients' status with data from the six months before the pilot, which was a short time to see improvement particularly when the patients were naturally deteriorating because of their dementia. “We stacked the deck against ourselves,” he said.

Still, the team saw striking improvements. The percentage of patients experiencing falls dropped from 71% to 14%. ED visits fell from 14% to 2%, and the number of hospital admissions dropped to zero. Sixty-seven percent of caregivers reported making changes to improve safety and 94% reported a better understanding of dementia.

Yvonne Eisner, 54, a self-employed woman living in Norwalk, Calif., was one of those caregivers. She was struggling to care for her elderly mother, who suffered from vascular dementia and lived with Eisner, her husband and her young son. “She would experience terrible mood swings and rages and no one told me this is typical behavior for people with dementia,” Eisner said.

After one particularly traumatic episode when her mother became violent, Eisner took her mother to her primary-care physician, who referred her to the Brain Health Program. Eisner's mom was enrolled as one of the original 46 members of the pilot, although she had to wait another eight months for the project to begin.

“It was worth the wait,” said Eisner, who recently testified before a congressional advisory committee about the program's benefits. “I had the support I needed to cope. Without the program, I would have had to put my mother in a nursing home. Instead, she passed away at home, with her family.”

CareMore is implementing the program at its clinics in the greater Los Angeles area and in Tucson, Ariz. The model takes time to put in place because it requires collaboration among many professionals. “We're rolling it out slowly because we don't want to inundate the system, but our hope is to get 1,000 patients enrolled,” Pratty said. He thinks the model could become widely used throughout the country.