Welcome to the Neighborhood: Building A Medical Home for Alzheimer’s Disease Soo Borson, MD Professor, Psychiatry and Behavioral Sciences Director, Memory.

Welcome to the Neighborhood:Welcome to the Neighborhood:Building A Medical Home for Building A Medical Home for

Alzheimer’s DiseaseAlzheimer’s Disease

Soo Borson, MDSoo Borson, MD

Professor, Psychiatry and Behavioral SciencesProfessor, Psychiatry and Behavioral SciencesDirector, Memory Disorders Clinic and Dementia Health Services Director, Memory Disorders Clinic and Dementia Health Services

Research GroupResearch GroupUniversity of WashingtonUniversity of Washington

Dementia Health Services

Research Group

University of Washington

© 3-11 Soo Borson MD© 3-11 Soo Borson MDHebert et al. Neurology 2004Hebert et al. Neurology 2004

The Population ImperativeThe Population Imperative

Framework: Caring SystemsFramework: Caring Systems

• PatientsPatients• FamiliesFamilies• ProvidersProviders

– Internal medicine/ Internal medicine/ primary careprimary care

– Specialty careSpecialty care– Social careSocial care

• Health systemsHealth systems– PayersPayers– Practice organizationsPractice organizations

© 3-11 Soo Borson MD© 3-11 Soo Borson MD

US Geriatric Specialist Workforce v. Persons with Alzheimer Dementia

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Geriatric Medicine Geriatric Psychiatry Persons with dementia

http://www.americangeriatrics.org/adgap/ADGAP; Brookmeyer et al, Am J Pub Health http://www.americangeriatrics.org/adgap/ADGAP; Brookmeyer et al, Am J Pub Health 1998 1998


A Primary Care Report CardA Primary Care Report CardStepStep % Complete% Complete GapGap

IdentificationIdentification 25-60% of cases25-60% of cases

(often late)(often late)

40-75% of cases40-75% of cases

Open disclosure and Open disclosure and discussiondiscussion

Unknown*Unknown* Probably largeProbably large

Stage-appropriate long-Stage-appropriate long-range health care planrange health care plan

~ 15%**~ 15%** LargeLarge

Care coordination and Care coordination and collaborationcollaboration

<20%***<20%*** LargeLarge

*< 50% of *< 50% of specialistsspecialists routinely disclose diagnosis (Raicher et al, Int Psychogeriatrics 2007). ** Wenger et al, Ann Intern routinely disclose diagnosis (Raicher et al, Int Psychogeriatrics 2007). ** Wenger et al, Ann Intern Med 2003; Chodosh et al, JAGS 2007; Borson et al, JGIM 2007. ***Overall estimate based on studies of referrals to Med 2003; Chodosh et al, JAGS 2007; Borson et al, JGIM 2007. ***Overall estimate based on studies of referrals to specialists, community resources, Alzheimer’s Association, explicit inclusion of caregivers as partners specialists, community resources, Alzheimer’s Association, explicit inclusion of caregivers as partners


Goals for Redesigning Goals for Redesigning Primary Dementia Care Primary Dementia Care

• Detect cognitive impairment and diagnose dementia when it Detect cognitive impairment and diagnose dementia when it is presentis present– Eliminate ‘don’t ask, don’t tell’Eliminate ‘don’t ask, don’t tell’

• Implement chronic care management modelImplement chronic care management model– Dementia is…Dementia is…

• A medical problem caused by specific disease processesA medical problem caused by specific disease processes

• A target for medical treatmentA target for medical treatment

• A risk factor for other problemsA risk factor for other problems

• A (usually) progressive condition with changing, stage-specific A (usually) progressive condition with changing, stage-specific management needsmanagement needs

• A major determinant of the context of careA major determinant of the context of care

Rationale for Redesign– Rationale for Redesign– Clinical Improvement Clinical Improvement

• Intervening early improves clinical outcomes for Intervening early improves clinical outcomes for patients and familiespatients and families11

– Medical treatmentMedical treatment• Donepezil for AD (multiple studies); other cholinesterase Donepezil for AD (multiple studies); other cholinesterase

inhibitorsinhibitors

– Psychological/behavioral interventionsPsychological/behavioral interventions– Social and environmental approachesSocial and environmental approaches

• Late detection delays secondary and tertiary Late detection delays secondary and tertiary preventionprevention

• Earlier detection of dementia makes sense Earlier detection of dementia makes sense

1 Feil et al for ACOVE team. JAGS 2007.

Rationale for Redesign – Rationale for Redesign – Health and Safety Systems Health and Safety Systems

• Health careHealth care– Delirium in hospital (OR 3.96, 95% CI 1.1-14.2) Delirium in hospital (OR 3.96, 95% CI 1.1-14.2) 11 – Low health literacy/adherence to pre-op instructions (OR Low health literacy/adherence to pre-op instructions (OR

4.0, 95% CI 1.6-9.8) 4.0, 95% CI 1.6-9.8) 22

– Deficit in knowledge/management of personal medicationsDeficit in knowledge/management of personal medications33

– Increased hospitalizations for ambulatory care sensitive Increased hospitalizations for ambulatory care sensitive conditions (OR 1.8, p < 0.0001) conditions (OR 1.8, p < 0.0001) 44

• Public safetyPublic safety– Driving riskDriving risk 5 5

• At home, in the communityAt home, in the community– Need for everyday support and assistance Need for everyday support and assistance 66

1.1. Alagiakrishnan et al. JAGS 2007. 2. Chew et al. Am J Surg 2004. 3. Lakey et al. Ann Alagiakrishnan et al. JAGS 2007. 2. Chew et al. Am J Surg 2004. 3. Lakey et al. Ann Pharmacother 2009. 4. Phelan et al (in review). Pharmacother 2009. 4. Phelan et al (in review). 5. AMA Driver Guide, 5. AMA Driver Guide, http://www.ama-assn.org/ama/pub 6. Scanlan et al. Am J Geriatr Psychiatry 2007 6. Scanlan et al. Am J Geriatr Psychiatry 2007


http://www.ama-assn.org/ama/pub

Essential Clinical and Administrative Skills Essential Clinical and Administrative Skills

• Timely identification and accurate diagnosis of Timely identification and accurate diagnosis of cognitive impairmentcognitive impairment

• Comfort with difficult discussions (e.g. diagnosis, Comfort with difficult discussions (e.g. diagnosis, driving, moving) driving, moving)

• Individualized health care plans for long-term Individualized health care plans for long-term palliationpalliation

• Planned collaboration with caregivers, care Planned collaboration with caregivers, care managers and specialistsmanagers and specialists

• Effective use of targeting and management Effective use of targeting and management tracking toolstracking tools


Screening for Cognitive Impairment Screening for Cognitive Impairment in Primary Care: RCTin Primary Care: RCT

• Four similar clinics in the same network, 2 Four similar clinics in the same network, 2 randomized to screening, 2 to usual practicerandomized to screening, 2 to usual practice

• QI framework – patient consent not requiredQI framework – patient consent not required• After vital signs, MA administered the Mini-CogAfter vital signs, MA administered the Mini-Cog

– Reliability high Reliability high – Refusals rare (<2%) Refusals rare (<2%)

• N = 524 screened (70% of patients age 65+ in N = 524 screened (70% of patients age 65+ in eligible clinic panels)eligible clinic panels)

• 18% of patients screened positive18% of patients screened positive

Borson S et al JGIM 2007 © 3-11 Soo Borson MD© 3-11 Soo Borson MD

© 3-11 Soo Borson MD© 3-11 Soo Borson MDBorson S et al JGIM 2007

Impact of Routine ScreeningImpact of Routine Screeningon Physician Practiceon Physician Practice

5-Year Follow On 5-Year Follow On

Figure 2: PCP Actions Following Screen Failure

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eventual dementia diagnosis any management

Figure 3: Proportion of Patients with Preventable Acute Care Episodes or Signs of Cognitive Trouble

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at least one ED visit at least one hospitalization signs of cognitive trouble in thechart

In progress: In progress:

Comparison with age-matched older adults screening negative 5 years earlierComparison with age-matched older adults screening negative 5 years earlier

DeMers S et al. AAGP Annual Meeting, Honolulu, 2009DeMers S et al. AAGP Annual Meeting, Honolulu, 2009 © 3-11 Soo Borson MD© 3-11 Soo Borson MD

Screening for Cognitive Impairment: Screening for Cognitive Impairment: Policy UpdatePolicy Update

• US Preventive Services US Preventive Services TaskTask Force Force– To update evidence and recommendations this yearTo update evidence and recommendations this year

• New Medicare benefit: Annual Wellness Visit (effective Jan New Medicare benefit: Annual Wellness Visit (effective Jan 2011)2011)– Cognitive assessment for early detectionCognitive assessment for early detection– Personalized health risk assessment (HRA) and prevention planPersonalized health risk assessment (HRA) and prevention plan

• IncentivesIncentives– For patients: no deductible or co-payFor patients: no deductible or co-pay– For physicians: reimbursement equivalent to Level 4 E/MFor physicians: reimbursement equivalent to Level 4 E/M

Fact sheet available on Fact sheet available on www.alz.org


http://www.alz.org/

Cognitive Assessment in the AWVCognitive Assessment in the AWV

• No method specified by CMSNo method specified by CMS• Acceptable pathways can includeAcceptable pathways can include

– A screening testA screening test– A question about cognition to the patient and/or familyA question about cognition to the patient and/or family– A spontaneous patient or family concern about the A spontaneous patient or family concern about the

patient’s cognitionpatient’s cognition

• Any/all of these pathways will generate a cohort Any/all of these pathways will generate a cohort of patients whose cognitive status should be of patients whose cognitive status should be further evaluatedfurther evaluated

• A ‘cognitive visit’ can then be scheduledA ‘cognitive visit’ can then be scheduled


What’s in a “Cognitive Visit”?What’s in a “Cognitive Visit”?• Clinical historyClinical history

–Basis for concernBasis for concern–First symptoms and signsFirst symptoms and signs–Context of emerging or worseningContext of emerging or worsening–Pattern of progressionPattern of progression–Functional deficits (advanced IADL; IADL, basic Functional deficits (advanced IADL; IADL, basic

self care ADL)self care ADL)

• Brief neurological examBrief neurological exam–Look for informative signs that suggest etiologyLook for informative signs that suggest etiology

• Confirmatory cognitive testingConfirmatory cognitive testing

• Risk factor reviewRisk factor review– Clinical vascular diseaseClinical vascular disease– Head injuriesHead injuries– Complications of surgery Complications of surgery – NeurotoxinsNeurotoxins– Prescription and OTC medicationsPrescription and OTC medications– Family historyFamily history– Recent hospitalization for acute or critical Recent hospitalization for acute or critical

illnessillness1 1 or complex surgical procedure or complex surgical procedure


1 Ehlenbach et al JAMA 2010

Further WorkupFurther Workup

• Use blood tests selectivelyUse blood tests selectively– Mainly for treatable confounders and problems related Mainly for treatable confounders and problems related

to effects of dementiato effects of dementia– Few dementias have specific clinical lab indicators Few dementias have specific clinical lab indicators

(e.g., HD, HIV, STD)(e.g., HD, HIV, STD)

• Think about neuroimagingThink about neuroimaging– Few patients require it for diagnosisFew patients require it for diagnosis

• Create a short list of most likely diagnosesCreate a short list of most likely diagnoses• If you’re not sure, consider specialty consultationIf you’re not sure, consider specialty consultation

© 3-11 Soo Borson MD

Diagnosis and DisclosureDiagnosis and Disclosure

• Whose responsibility?Whose responsibility?– May share with a specialistMay share with a specialist

• How to do it?How to do it?– Patient-centered communicationPatient-centered communication

• Patient’s thoughts, feelings, fearsPatient’s thoughts, feelings, fears• Caregiver’s knowledge and concernsCaregiver’s knowledge and concerns• Physician’s positive affect, direct language, optimism Physician’s positive affect, direct language, optimism

• When to follow up?When to follow up?– Anticipate adjustment periodAnticipate adjustment period

• See a month or less after the diagnosis – check inSee a month or less after the diagnosis – check in• Answer questions, respond to concernsAnswer questions, respond to concerns• Refine management and follow up planRefine management and follow up plan

Boise et al, Gerontol 1999; Iliffe et al, Int J Geriatr Psychiatry 2009; Eccles et al, Int J Behav Boise et al, Gerontol 1999; Iliffe et al, Int J Geriatr Psychiatry 2009; Eccles et al, Int J Behav Med 2009; Zaleta and Carpenter Am J Alz Other Dem 2010 Med 2009; Zaleta and Carpenter Am J Alz Other Dem 2010 © 3-11 Soo Borson MD© 3-11 Soo Borson MD

Next Steps: Prepare for Chronic CareNext Steps: Prepare for Chronic Care

MMSE at Diagnosis

Median Survival (years)

Maximum Survival (years)

25-30 (very mild) ~ 7 >15

22-24 (mild) 5.5 >13

18-21 (moderate) 5 ~13

≤17 (moderate to severe)

4 ~10

Data on Alzheimer’s disease from Group Health Cooperative ADPR/ACT studies (n = 521). Data on Alzheimer’s disease from Group Health Cooperative ADPR/ACT studies (n = 521). Larson EB et al. Ann Intern Med 2004. Most other studies find much shorter survival, since Larson EB et al. Ann Intern Med 2004. Most other studies find much shorter survival, since diagnosis occurs later.diagnosis occurs later. © 3-11 Soo Borson MD© 3-11 Soo Borson MD

Integrate DementiaIntegrate Dementia

• Palliative philosophy from diagnosis to death, since Palliative philosophy from diagnosis to death, since dementia is a…dementia is a… Target of treatmentTarget of treatment Modifier of care for other conditionsModifier of care for other conditions Prognostic indicatorPrognostic indicator Risk indicatorRisk indicator

• Care is stage-specificCare is stage-specific Components of palliation vary over timeComponents of palliation vary over time

• Care is always a collaborationCare is always a collaboration– You, the patient, and the familyYou, the patient, and the family– A medical dementia specialist, when neededA medical dementia specialist, when needed– A psychosocial care manager, especially at moderate dementia A psychosocial care manager, especially at moderate dementia

stages and beyond, or when families are stressedstages and beyond, or when families are stressed© 3-11 Soo Borson MD© 3-11 Soo Borson MD


Problems Peak at Different Times in Problems Peak at Different Times in the Course of ADthe Course of AD

0 1 2 3 4 5 6 7 8 9

Years from symptom onset

Cognitive ability

Functional ability

Behavioral problems

Caregiver time demand/stress

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Stage and duration of usual clinical trials of antidementia drugs

Stage-Specific Management ConceptsStage-Specific Management Concepts

• Very early stage (“MCI”) Very early stage (“MCI”) – educate, support – educate, support healthy habits, prevent 2healthy habits, prevent 2OO and 3 and 3OO complications, re-evaluate cognition ove4r complications, re-evaluate cognition ove4r time, discuss end of life preferencestime, discuss end of life preferences

• Mild to moderate stage Mild to moderate stage – treat dementia, find – treat dementia, find and manage risks, set goals for comorbid and manage risks, set goals for comorbid chronic conditions, support good caregiver-chronic conditions, support good caregiver-patient dynamics and regular medical f/u; patient dynamics and regular medical f/u; bring secondary family members in; review bring secondary family members in; review end of life wishes; encourage legal review end of life wishes; encourage legal review (DPOA for finances and health care, will, (DPOA for finances and health care, will, POLST) POLST)


• Moderate to severe stage Moderate to severe stage – 24 hr supervision – 24 hr supervision and shared caregiving; prevent injury, expect and shared caregiving; prevent injury, expect behavioral problems, hospitalizations, and behavioral problems, hospitalizations, and caregiver burnout; review and simplify caregiver burnout; review and simplify medications; surgery only for urgent conditions medications; surgery only for urgent conditions with favorable prognosis; update POLSTwith favorable prognosis; update POLST

• Advanced and terminal stage Advanced and terminal stage – remove – remove unnecessary medications; update POLST; unnecessary medications; update POLST; provide hospice/comfort care; with caregivers, provide hospice/comfort care; with caregivers, plan for possible terminal event scenarios and plan for possible terminal event scenarios and actions appropriate to those – the ‘what if’ actions appropriate to those – the ‘what if’ conversation conversation


A Comprehensive Framework A Comprehensive Framework for Dementia Care for Dementia Care

Patient

Diagnosis

and

Staging

Neurobehavioral Assessment & Management

Medical Comorbidity and Risk Management

Caregiver Assessment, Counseling,

Services, and Planning

Dementia as a disease• Diagnose etiology /type

• Establish stage (cognitive, functional)

• Consider cognitive enhancing medications

• Support adjustment to diagnosis

• Anticipate risks specific to types/stages of dementia

Comorbid medical conditions and risks• Manage to protect the brain

• Identify/implement adherence supports

• Address key safety issues (e.g. driving, falls, injury potential)

• Reframe goals to match prognosis/stage

• Coordinate care with other providers

• Palliation at every stage

Neuropsychiatric probems • Recognize depression, demoralization, loss of confidence, anxiety, agitation, aggression, psychosis

• Analyze behavioral problems – causes and consequences

• Implement practical psychosocial interventions

• Train caregivers in hands-on prevention and management

• Use psychotropic medications selectively

Caregiver issues• Encourage realistic expectations

•Assess and respond to stress and burden

• Identify caregivers needing community based services, refer, and follow up

• Track ongoing needs and gaps

• Provide clinical options to optimize adjustment across stages

Operationalizing the ModelOperationalizing the Model


Measuring the Quality of Dementia Measuring the Quality of Dementia CareCare

• Patient and practice levelPatient and practice level– ACOVE-3 indicatorsACOVE-3 indicators– Emerging consensus measures (AMA)Emerging consensus measures (AMA)

• Health system level Health system level – Uptake of annual wellness visits and their cognitive Uptake of annual wellness visits and their cognitive

assessment component assessment component – Reduction in avoidable hospitalizations and post-Reduction in avoidable hospitalizations and post-

hospital readmissionshospital readmissions


ACOVE-3 Dementia QIs ACOVE-3 Dementia QIs

• Cognitive and functional screening/evaluationCognitive and functional screening/evaluation• Medication review and adjustmentMedication review and adjustment• Neurological assessment Neurological assessment • Lab testing (including HIV if at risk)Lab testing (including HIV if at risk)• Depression screening Depression screening • Cholinesterase inhibitor discussionCholinesterase inhibitor discussion• Behavioral symptoms of dementiaBehavioral symptoms of dementia• Stroke prophylaxisStroke prophylaxis• Caregiver support and patient safetyCaregiver support and patient safety• Driving (state law variations)Driving (state law variations)• Restraint documentation and communication (hospital)Restraint documentation and communication (hospital)

Feil et al. JAGS 2007. © 3-11 Soo Borson MD© 3-11 Soo Borson MD

AMA Consensus Performance MeasuresAMA Consensus Performance Measures• AMA PCPI with AAN, AGS, AMDA, and APA/AAGP – for AMA PCPI with AAN, AGS, AMDA, and APA/AAGP – for

patients with a dementia diagnosispatients with a dementia diagnosis• 10 domains of quality10 domains of quality

– Dementia stagingDementia staging– Cognitive assessmentCognitive assessment– Functional status assessmentFunctional status assessment– Neuropsychiatric symptom assessmentNeuropsychiatric symptom assessment– Screening for depressive symptomsScreening for depressive symptoms– Management of neuropsychiatric symptomsManagement of neuropsychiatric symptoms– Counseling about safety mattersCounseling about safety matters– Counseling about drivingCounseling about driving– Comprehensive end of life counseling/advance care planningComprehensive end of life counseling/advance care planning– Caregiver education and supportCaregiver education and support


Setting Up a Care CollaborativeSetting Up a Care Collaborative• Dementia Care Manager (DCC) ModelsDementia Care Manager (DCC) Models

– Callahan et al. JAMA 2006Callahan et al. JAMA 2006• Interdisciplinary team led by an advanced practice nurse Interdisciplinary team led by an advanced practice nurse

– Vickrey et al. Ann Internal Med 2006Vickrey et al. Ann Internal Med 2006• Dementia care guideline model, non-medical care managers Dementia care guideline model, non-medical care managers

in a primary care setting, involvement of Alzheimer’s in a primary care setting, involvement of Alzheimer’s Association and social care agenciesAssociation and social care agencies

• Primary Care Practice RedesignPrimary Care Practice Redesign– Reuben et al. JAGS 2010Reuben et al. JAGS 2010

• Six components, internal practice change + Alzheimer’s Six components, internal practice change + Alzheimer’s AssociationAssociation

• Specialty-Based Medical Home ModelSpecialty-Based Medical Home Model– Lessig et al. JAGS 2006Lessig et al. JAGS 2006

• Cooperative Dementia Care Clinics and Dimensional Cooperative Dementia Care Clinics and Dimensional Approach to CareApproach to Care


Advanced Practice Nurse Model Advanced Practice Nurse Model (Callahan et al.)(Callahan et al.)

DesignDesign SettingSetting OutcomesOutcomes

• Clinical trial, 153 Clinical trial, 153 patients and caregivers patients and caregivers randomized by clinicrandomized by clinic

• Intervention (n=84) v. Intervention (n=84) v. augmented usual care augmented usual care (n=69)(n=69)

• Intervention = 8 Intervention = 8 standardized protocols standardized protocols for BPSD for BPSD

• 10 clinics @ 2 US 10 clinics @ 2 US university affiliated health university affiliated health care systemscare systems

• 89% triggered 89% triggered ≥ 1 ≥ 1 management protocol, management protocol, mean of 4 protocols/ mean of 4 protocols/ patientpatient

• 80% v. 55% prescribed 80% v. 55% prescribed ChEIs ChEIs

• 45% v 28% Rx 45% v 28% Rx antidepressantsantidepressants

• Fewer BPSDs (NPI) Fewer BPSDs (NPI)

• Lower CG distressLower CG distress


Dementia Care Guideline Model Dementia Care Guideline Model (Vickrey et al.)(Vickrey et al.)

Design Design SettingSetting OutcomesOutcomes

• Clinics randomized by Clinics randomized by practice type, dyads by practice type, dyads by physicianphysician

• 408 patient-caregiver 408 patient-caregiver dyads (n=238 intervention)dyads (n=238 intervention)

• 23 Dementia Care 23 Dementia Care Guidelines developed by Guidelines developed by consensus across 4 domains consensus across 4 domains (assessment, treatment, (assessment, treatment, education and support, education and support, safety)safety)

• 18 clinics (9 18 clinics (9 intervention)intervention)

• 3 health care 3 health care organizationsorganizations

• 3 community 3 community agenciesagencies

• ↑ ↑ adherence to DGLs adherence to DGLs (63.9% v 32.9%)(63.9% v 32.9%)

• ↑ ↑ care quality for 21/23 care quality for 21/23 DGLsDGLs

• ↑ ↑ community agency community agency assistance assistance

• ↑ ↑ CG social support & CG social support & assistance with unmet assistance with unmet needs needs



Primary Care Practice Redesign Primary Care Practice Redesign (Reuben et al)(Reuben et al)

Design Design SettingSetting OutcomesOutcomes

• Pre-post intervention study in Pre-post intervention study in 2 practices2 practices• ACOVE-3 quality indicators ACOVE-3 quality indicators for dementia carefor dementia care• Intervention componentsIntervention components

• Screening (casefinding)Screening (casefinding)

• Dementia-specific clinical data Dementia-specific clinical data collectioncollection• EMR promptsEMR prompts• Pt/family education materials; Pt/family education materials; referral to local Alzheimer’s referral to local Alzheimer’s AssociationAssociation• MD decision support/educationMD decision support/education

• 2 large 2 large community-community-based based physician physician practicespractices

• One of two One of two practices showed practices showed significant intervention significant intervention effects – more effects – more referrals to the local referrals to the local Alz Assoc (<1/5), Alz Assoc (<1/5), better overall quality better overall quality

Common to These ModelsCommon to These Models

• Patient eligibility defined by diagnosis of Patient eligibility defined by diagnosis of dementia and participation of a family caregiverdementia and participation of a family caregiver

• Addition of psychosocial management optionsAddition of psychosocial management options• Care partnership with the family Care partnership with the family • Specified communication pathwaysSpecified communication pathways• Tools for measuring outcomesTools for measuring outcomes• Relatively small effect sizesRelatively small effect sizes

Finding High-Needs Patients and Finding High-Needs Patients and CaregiversCaregivers

• Goal: predict service needs and gaps by data Goal: predict service needs and gaps by data easily acquired in primary care easily acquired in primary care

• Community sample of 215 patient/caregiver pairsCommunity sample of 215 patient/caregiver pairs– Dementia-related services needed/used in past year, 8 Dementia-related services needed/used in past year, 8

physician-initiated and 8 psychosocial case manager-physician-initiated and 8 psychosocial case manager-initiated. Scored as # needs and # gaps. initiated. Scored as # needs and # gaps.

– Caregiver stress (1 item, scored 1-5) and # of patient Caregiver stress (1 item, scored 1-5) and # of patient behavior problems (5 items, scored 0-5)behavior problems (5 items, scored 0-5)

• Result: stress and behavior problems by far the Result: stress and behavior problems by far the strongest predictors of service needs and gapsstrongest predictors of service needs and gaps



Services: Physician ManagementServices: Physician Management

Low behavior problems

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Patient Behavior

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problems

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problems

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stress + 0-1 behavior problems

Urgent, intensive

physician/case manager

collaboration May need

geropsychiatrist

Primary Care Encourage reporting of

new problems

Primary Care Refer to case

manager


Physician-Based Medical HomePhysician-Based Medical Home(Lessig et al)(Lessig et al)

DesignDesign SettingSetting ExperienceExperience

• Clinical quality Clinical quality improvement pilotimprovement pilot

• 21 initial patient/family 21 initial patient/family dyads (now 50)dyads (now 50)

• Shared medical visitsShared medical visits

• 3 initial groups: early onset, 3 initial groups: early onset, late onset, and medically late onset, and medically complexcomplex

Dementia specialty Dementia specialty clinicclinic

• ↓ ↓ unnecessary unnecessary hospitalizations and hospitalizations and clinic visitsclinic visits

• ↑ ↑ Pt & Cg support and Pt & Cg support and problem solvingproblem solving

• Satisfaction with care Satisfaction with care

• More efficient use of More efficient use of physician and social physician and social work timework time

• More timely acceptance More timely acceptance of shared care of shared care


Improving Care:Improving Care:Moving Into the Medical Home NeighborhoodMoving Into the Medical Home Neighborhood

• Patient Centered Medical HomePatient Centered Medical Home– Central hub for information, primary care, and care Central hub for information, primary care, and care

coordination for a defined group of patientscoordination for a defined group of patients• Each patient has a personal physician who directs a team Each patient has a personal physician who directs a team

• Collective responsibility for the patient’s health careCollective responsibility for the patient’s health care

• Patient Centered Medical NeighborPatient Centered Medical Neighbor– Specialty/subspecialty practice committed to Specialty/subspecialty practice committed to

collaboration with a PCMHcollaboration with a PCMH• Standards for linking with a PCMHStandards for linking with a PCMH

• For some patients, PCMN physician may provide the PCMH For some patients, PCMN physician may provide the PCMH

Laine, Sinsky, Lee: Ann Intern Med 2011Laine, Sinsky, Lee: Ann Intern Med 2011



Thanks to…Thanks to…

Mary Lessig BSMary Lessig BSJim Scanlan PhDJim Scanlan PhD

Shaune DeMers MDShaune DeMers MDPeter Vitaliano PhDPeter Vitaliano PhD

Jeff Hummel MD, MPHJeff Hummel MD, MPHKathy Gibbs RN, CNSKathy Gibbs RN, CNSTeresa Holder MSWTeresa Holder MSW

Beth Zuhr BABeth Zuhr BA

and our residents and fellows whose training turned the practiceand our residents and fellows whose training turned the practice into words into words

Welcome to the Neighborhood: Building A Medical Home for Alzheimer’s Disease Soo Borson, MD Professor, Psychiatry and Behavioral Sciences Director, Memory.

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