Improving How People Living With Dementia Are Selected for Care Coordination

Improving How People Living With Dementia Are Selected for Care Coordination: A Pragmatic Clinical Trial Embedded in an Accountable Care Organization

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.

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.

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.

Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician.

If proxies for patients in intervention group report on the survey that they experience difficulty coordinating care among the patients' providers, the patient will be selected for care management services. Those services will attempt to address the problems with care coordination that the proxy reported.

If a patient is discharged from a hospital, the patient will be selected for care management services.

Appropriateness, as measured by the proportion of problems with communication that are identified by participants and that are in scope for the work of care coordinators

Fidelity, as measured by the proportion of eligible individuals who receive care coordination services

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