Quincy M. Samus

Describe the prevalence and types of unmet needs among community-dwelling dementia care partners (CPs) and determine associations between unmet needs with protective factors, risk factors and outco...

MIND at Home is a comprehensive, home‐based care coordination intervention for people with Alzheimer’s disease or related dementias (A/D) who live in the community and for their family caregivers. Developed by researchers at Johns Hopkins University (JHU), the model has been shown to extend the time a person with A/D remains at home for almost two years, as well as improved quality of life and quality of care and reduced caregiver burden. The MIND at Home pilot at Superior HealthPlan is a collaboration between Centene Corporation, JHU, and Superior HealthPlan (Superior). The goal of the MIND at Home pilot is to adapt, implement, and evaluate the impact of MIND at Home within Superior’s Medicaid population. The pilot is structured as an interventional study of the MIND at Home program versus a propensity score‐matched (PSM) comparison group receiving standard‐of‐care. The duration of the pilot is approximately 12 months, with longitudinal follow‐up at 18 and 24 months. The pilot population includes Superior HealthPlan Medicaid members (receiving Long‐Term Services & Supports) who are community‐residing and have a confirmed diagnosis of A/D. The study has enrolled approximately 300 participants who have received the intervention. An analysis of claims data for participants receiving the MIND at Home intervention indicates the program increased primary care utilization (+10.0%) while reducing emergency department (ED) utilization (‐15.8%), polypharmacy (‐5.0%), and total spend (‐1.35%). Consumer survey results indicate high levels of satisfaction among both pilot participants and their family caregivers and case studies anecdotally illustrate the significant impacts the MIND at Home program has had on participant and caregiver quality of life. Preliminary outcomes of the pilot indicate the MIND at Home program reduces high cost healthcare utilization – particularly ED and polypharmacy – and overall participant costs. Additional outcomes illustrate participants are highly satisfied with the MIND at Home program and have experienced dramatic increases in quality of life. This pilot showcases the value of operationalizing this evidence‐based academic care model for A/D in a Medicaid population and that collaboration across academic research, industry, and government‐sponsored healthcare programs can result in improved outcomes for individuals with A/D.

Background: Most people living with dementia want to remain living in their own homes and are supported to do so by family carers. No interventions have consistently demonstrated improvements to people with dementia’s life quality, functioning, or other indices of living as well as possible with dementia. We have co-produced, with health and social care professionals and family carers of people with dementia, a new intervention (NIDUS-family). To our knowledge, NIDUS-family is the first manualised intervention that can be tailored to personal goals of people living with dementia and their families and is delivered by facilitators without clinical training. The intervention utilizes components of behavioural management, carer support, psychoeducation, communication and coping skills training, enablement, and environmental adaptations, with modules selected to address dyads’ selected goals. We will evaluate the effect of NIDUS-family and usual care on goal attainment, as measured by Goal Attainment Scaling (GAS) rated by family carers, compared to usual care alone at 12-month follow-up. We will also determine whether NIDUS-family and usual care is more cost-effective than usual care alone over 12 months. Methods: A randomised, two-arm, single-masked, multi-site clinical trial involving 297 people living with dementia-family carer dyads. Dyads will be randomised 2:1 to receive the NIDUS-family intervention with usual care (n = 199) or usual care alone (n = 98). The intervention group will be offered, over 1 year, via 6–8 video call or telephone sessions (or face to face if COVID-19 restrictions allow in the recruitment period) in the initial 6 months, followed by telephone follow-ups every 1–2 months to support implementation, with a trained facilitator. Discussion: Increasing the time lived at home by people living with dementia is likely to benefit lives now and in the future. Our intervention, which we adapted to include remote delivery prior to trial commencement due to the COVID-19 pandemic, aims to address barriers to living as well and as independently as possible that distress people living with dementia, exacerbate family carer(s) stress, negatively affect relationships, lead to safety risks, and frequently precipitate avoidable moves to a care home. Trial registration: International Standard Randomised Controlled Trials Number ISRCTN11425138. Registered on 7 October 2019

Background: MIND at Home, a value‐based innovation, is a comprehensive, home‐based care coordination program for people with dementia and their carers to identify and address a broad set of health determinants to improve health, clinical outcomes, and reduce costs. We present pooled trial data evaluate change in 12‐month health care utilization patterns among a racially and cognitively diverse group of persons living with dementia who received MIND at Home.Method: Pre‐post, adjusted Poisson regression models were used to evaluate health care utilization patterns for a pooled sample of persons with dementia receiving MIND at Home (n=391) in the 12 month period after enrollment in the program with the 12 month period prior to enrollment. Hospitalizations, ED visits, outpatient visits, home and community‐based services (HCBS) were ascertained via proxy‐report from carers.Result: The mean number of hospital admissions decreased by 27% in the one year period after baseline (95% CI: 6%, 44%, p=0.01) compared with the year prior. Adjusted rates of one or more hospitalizations declined from 36.8% to 32.5%, with a crude rate reduction of 11.6% (unadjusted) between pre‐and post‐periods. Mean number of HCBS services used increased by 70% (95% CI: 54%, 88%, ppp=0.18).Conclusion: Results provide compelling new quasi‐experimental data that supports the impact of the MIND at Home program on changing health care utilization patterns and is in line with our prior findings. Persons who received MIND at Home were less likely to use high cost acute health services (inpatient) and more likely to use more cost‐efficient services like home and community based services and physician services in the year after enrollment compared to the year prior. These data imply a potential cost benefit of the MIND at Home dementia care coordination program.

Background: Scalable, home‐based approaches for the delivery of comprehensive dementia care that bridge medical, social, and supportive care services are needed to improve outcomes and care value for persons living with dementia (PWD) and family carers. We present results from a CMS‐funded Healthcare Innovations Award evaluating the 18‐month impact of a comprehensive home‐based dementia care coordination program, MIND at Home, on clinical and quality of life outcomes in a racially and socioeconomically diverse group of community‐living PWD and family carers.Methods: This is a prospective, within‐subject, study to evaluate change (baseline to 9‐months, and baseline to 18‐months) in clinical and quality of life outcomes among 342 PWD in Maryland who received MIND at Home. Within‐group changes on dementia‐related unmet care needs (59 items total, 13 domains), neuropsychiatric behaviors (NPI), quality of life (QOL‐AD), carer burden (Zarit Burden Interview), carer depression (PHQ‐9) were assessed using longitudinal mixed effects models. We also tested whether change in outcomes over time was moderated by baseline cognition, living arrangement, or race (Caucasian vs. Non‐Caucasian) in post hoc analyses.Results: In adjusted linear mixed models, PWD and carers had significantly fewer total percent unmet dementia‐related needs (PWD: β=‐19.95, SE 0.7, p<0.001; CG: β =‐28.30 SE 0.9, p<0.001) and percent unmet in all need subdomains (all p<0.01), fewer behavioral symptoms (NPI) (β = ‐5.16, SE 1.4, p<0.001), reduced caregiver burden (ZBI short) (β = ‐1.69, SE 0.6, p=0.005), and reduced caregiver distress with behavioral symptoms (β = ‐1.63, SE 0.8), p=0.03) from baseline to 18 months. Carer depression trended towards improvement (PHQ‐9, β = ‐0.63, SE 0.37, p=0.086). No statistically significant change in QOL‐AD scores were observed. Most interaction effects were not significant, however non‐Caucasians tended to benefit more on several outcomes compared to Caucasians.Conclusion: MIND is a scalable home‐based dementia model of care that promotes evidence‐based dementia care strategies addressing range of key medical, social, and environmental determinants of health. This quasi‐experimental analysis provides new evidence of effectiveness for improving outcomes for both PWD and their caregivers over time to and contributes important new longitudinal data to support the program’s value proposition to potential adopters.

Introduction: Despite availability of effective care strategies for dementia, most health care systems are not yet organized or equipped to provide comprehensive family-centered dementia care management. Maximizing Independence at Home-Plus is a promising new model of dementia care coordination being tested in the U.S. through a Health Care Innovation Award funded by the Centers for Medicare and Medicaid Services that may serve as a model to address these delivery gaps, improve outcomes, and lower costs. This report provides an overview of the Health Care Innovation Award aims, study design, and methodology. Methods: This is a prospective, quasi-experimental intervention study of 342 community-living Medicare–Medicaid dual eligibles and Medicare-only beneficiaries with dementia in Maryland. Primary analyses will assess the impact of Maximizing Independence at Home-Plus on risk of nursing home long-term care placement, hospitalization, and health care expenditures (Medicare, Medicaid) at 12, 18 (primary end point), and 24 months, compared to a propensity-matched comparison group. Discussion: The goals of the Maximizing Independence at Home-Plus model are to improve care coordination, ability to remain at home, and life quality for participants and caregivers, while reducing total costs of care for this vulnerable population. This Health Care Innovation Award project will provide timely information on the impact of Maximizing Independence at Home-Plus care coordination model on a variety of outcomes including effects on Medicaid and Medicare expenditures and service utilization. Participant characteristic data, cost savings, and program delivery costs will be analyzed to develop a risk-adjusted payment model to encourage sustainability and facilitate spread.

Introduction: A national consensus panel was convened to develop recommendations on future directions for home‐based dementia care (HBDC).Methods: The panel summarized advantages and challenges of shifting to HBDC as the nexus of care and developed consensus‐based recommendations.Results: The panel developed five core recommendations: (1) HBDC should be considered the nexus of new dementia models, from diagnosis to end of life in dementia; (2) new payment models are needed to support HBDC and reward integration of care; (3) a diverse new workforce that spans the care continuum should be prepared urgently; (4) new technologies to promote communication, monitoring/safety, and symptoms management must be tested, integrated, and deployed; and (5) targeted dissemination efforts for HBDC must be employed.Discussion: HBDC represents a promising paradigm shift to improve care for those living with dementia and their family caregivers: these recommendations provide a framework to chart a course forward for HBDC.