Implementation of the Care Ecosystem Training Model for Individuals With Dementia in a High-risk, Integrated Care Management

Not Applicable

Completed

• Conditions: Dementia; Alzheimer Disease
• Interventions: Behavioral: Care Ecosystem

• Registration Number: NCT04556097
• Lead Sponsor: Mclean Hospital

Brief Summary

There is growing need for to provide high quality care for persons living with dementia (PLWD) and provide support for care partners in the primary care setting. The Care Ecosystem model is a telephone-based dementia care program that provides standardized, proactive, personalized, and scalable support and education for care partners. The Care Ecosystem model has demonstrated an improvement in patient quality of life, reduced unnecessary healthcare expenditures, and a decrease in care partner burden and depression.

In this pilot the investigators will assess the feasibility of implementing and measuring outcomes of an adapted Care Ecosystem training model for primary care nurse managers serving a diverse panel of PLWD and their care partners in primary care practices participating in the Mass General Brigham healthcare system's Integrated Care Management Program in Boston, MA. The study team will leverage the Mass General Brigham electronic medical record to determine the feasibility of collecting the primary clinical outcome defined as emergency department visits among the PLWD cared for by the primary care practices. The investigative team will also assess the feasibility of implementation, number of contacts between nurse care managers and care partners, and documented advance care planning.

Detailed Description

Not available

Study Timeline

• Study First Submitted: 2020-06-17
• Study First Submitted QC: 2020-09-15
• Study First Posted: 2020-09-21
• Study Start: 2020-12-15
• Primary Completion: 2021-07-31
• Study Completion: 2021-11-03
• Status Verified: 2022-03
• Last Update Submitted: 2022-03-23
• Last Update Posted: 2022-03-25

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 524

Inclusion Criteria

• Medicare beneficiary aligned to the Partners Medicare ACO
• ICD-10 diagnosis code consistent with dementia in Medicare claims between August 1, 2019 and July 31, 2020 (excluding diagnoses for diagnostic testing services)
• Actively engaged in care management services with a nurse care manager enrolled in the study

Exclusion Criteria

• Permanent resident of long-term care or deceased at the start of the study

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Delayed Training	Care Ecosystem	The Delayed Training arm will be the second group of nurse care managers to receive training.
Early Training	Care Ecosystem	Nurse care managers will be randomized to either early or delayed adapted Care Ecosystem training. The Early Training arm will be the first group to receive training and the first to have the opportunity to use the training in a clinical setting. We anticipate that each nurse care manager will manage 10 PWLD and we anticipate a 50% response rate/data availability, yielding 75 patients per arm.

Primary Outcome Measures

Name	Time	Method
Emergency department visits	6 months	Defined as the count of emergency department visits within the specified time period based on Medicare parts A and B. Emergency department visits resulting in in patient admission will be excluded.

Trial Locations

Locations (1)

Mass General Brigham; 🇺🇸 Somerville, Massachusetts, United States