The Care Ecosystem Consortium Effectiveness Study

Inclusion criteria, PWD participant Age 18+ Provision of verbal consent (or surrogate consent), documented in REDCap, and assent Willingness to enroll in the Care Ecosystem program Lives in the community (i.e., not in an assisted living, board & care, skilled nursing or memory care facility) at the time of enrollment Have a dementia diagnosis documented in the EHR Has had a visit with the referring provider in the last 12 months Has a caregiver with a primary level of responsibility for the patient who is eligible and willing to participate Inclusion Criteria, Caregiver participant Age 18+ Provision of verbal consent, documented in REDCap Has a primary level of responsibility for the care of a PWD-participant who is enrolling in the study Willingness to enroll in the Care Ecosystem program and complete surveys Exclusion Criteria, PWD participant PWD-participants for whom a substantial amount of the patient's healthcare utilization records cannot be accessed for research purposes by the study team. (see Note) Is currently, or was ever enrolled, in the Care Ecosystem program. Medical documentation indicates that the patient's dementia is a non-progressive type (e.g., due to a head injury or stroke, and not expected to progress). Note: This exclusion criteria will be operationalized differently at each site based on variations in data access options for their patient population; these options will include EHR and Medicare. A small percentage of participants may be enrolled from underrepresented populations for whom a substantial amount of utilization records cannot be accessed with written approval from the study PI. All participants must be affiliated with one of the 6 participating health systems: Ochsner Health System Providence Health & Services Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center HealthPartners Institute University of Colorado, Denver University of California, San Francisco