Improving How People Living With Dementia Are Selected for Care Coordination

Not Applicable

Completed

Interventions: Behavioral: Care coordination delivered based on usual care (e.g. discharge from hospital)
Behavioral: Care coordination delivered based on perceived need

Brief Summary: Many people living with dementia (PLWD) and their care partners may benefit from the assistance of a care coordinator, a member of the medical team who facilitates communication among all the people involved. However, care coordinators' time is limited, and there is uncertainty about which patients should be selected to receive their help. This pragmatic clinical trial embedded in an accountable care organization will determine the comparative effectiveness of two approaches for assigning care coordinators to PLWD.

Detailed Description: This project will use a pragmatic clinical trial embedded in an accountable care organization (ACO) to determine the comparative effectiveness of two different approaches for selecting PLWD to receive support from care coordinators: (1) an approach that assigns PLWD to care coordinators based on care partners' self-reported difficulty with care coordination, or (2) usual care, which generally assigns PLWD to care coordinators after hospital discharge, regardless of perceived need. The investigators will include community-dwelling Medicare beneficiaries ≥65 years old with dementia who have been attributed to the NewYork Quality Care ACO and who have fragmented care. The investigators will randomize the participants into two groups. This study is highly pragmatic, and the intervention is sustainable and scalable. Moreover, the proposed approach has the potential to improve care delivery and outcomes for PLWD.

Recruitment & Eligibility

Inclusion Criteria

Medicare beneficiaries ≥65 years old who:
Are attributed to the NewYork Quality Care accountable care organization by Medicare,
Have dementia (as measured in claims using the Bynum standard 1-year definition),
Reside in the community, and
Had fragmented ambulatory care in the previous 12 months (defined as a reversed Bice-Boxerman Index greater than or equal to the median score for this population, using Medicare claims)

Exclusion Criteria

Those who reside in long-term care or nursing home facilities (based on addresses in Medicare claims), or
Enrolled in home hospice

Arm && Interventions

Group	Intervention	Description
Control	Care coordination delivered based on usual care (e.g. discharge from hospital)	Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician.
Intervention	Care coordination delivered based on perceived need	The intervention group will assign care coordinators to PLWD based on perceived need for assistance with care coordination. Perceived need will be measured through a proxy's responses to a previously validated telephone survey on perceptions of care coordination.

Primary Outcome Measures

Name	Time	Method
Number of Emergency Department Visits or Hospital Admissions	Over 12 months (beginning 1 month after the start of care coordination)	Occurrence of an emergency department visit or hospital admission, as measured in Medicare claims

Secondary Outcome Measures

Name	Time	Method
Acceptability	Up to 1 year	The number of people who accepted care management in each group
Appropriateness	Up to 1 year	The number of people with problems in scope for care coordinators, out of all people who received care management
Fidelity	Up to 1 year	The number of people who actually received care coordination services, out of all of those who agreed to receive it
Efficiency	Up to 1 year	The number of care coordinator encounters in each group. This measure allows more than one encounter per person.