California's Medicaid program, Medi-Cal, expanded its benefits in July 2022 for older members to include an annual screening for dementia. Providers using this benefit were required to take an accompanying training and therefore funded a program called Dementia Care Aware to provide the training and disseminate it to eligible primary care clinicians across the state. Led by the University of California, San Francisco (UCSF), Dementia Care Aware initially partnered with other UC campuses and dementia-focused community-based organizations to realize the goal of reaching primary care in all of California's 58 counties. As of October 2024, Dementia Care Aware continues in a partnership between the West Health Institute and UCSF. Attendees will learn the key accomplishments of the program, including the training of almost 6000 learners in the state; the process and outcomes of creating the screening approach called the “cognitive health assessment”; strategies for attracting more learners; environmental factors improving or hindering uptake of the training and screening benefit; and the success in building a research consortium in two county public health systems (Los Angeles, San Francisco) to study the impact of screening programs there on the quality of care provided to patients who screened positive. The presentation will summarize the key learnings and challenges of standing up a statewide program to support diverse primary care practices in taking up a cognitive screening benefit for low-income residents.

New blood-based and digital biomarkers for Alzheimer’s disease (AD) make early detection possible at stages when novel, disease-specific therapies are likely to be most effective. These approaches may offer less invasive, more cost-effective alternatives to traditional methods such as cerebrospinal fluid (CSF) collection or positron emission tomography (PET) imaging for diagnosing and staging AD. Building care pathways leveraging blood-based and digital biomarkers starts with understanding the current biomarker landscape and considering opportunities for widespread implementation in primary care clinical practice. A multidisciplinary team representing neurology, neuropsychology, geriatrics, primary care, epidemiology, laboratory programs, and patient advocacy was convened to review a summary of current biomarker research findings and discuss barriers and opportunities to implement biomarkers as part of an AD consensus-driven clinical care pathway. The emergence of biomarkers has shifted diagnosis from primarily clinical to a biological definition of AD. However, there is currently no consensus on where biomarkers fit within an AD care pathway and when they should be utilized in primary care or dementia specialist care settings. We found a relative paucity of published data on biomarker test accuracy in diagnosis outside tightly controlled research settings, limiting guidance around how results should be interpreted and managed in real-world care settings. Evidence gaps are especially pressing for heterogeneous, diverse populations under-represented in AD research. New biomedical therapies specific to the pathobiology of AD are driving research on blood and digital biomarkers to inform optimal ways to accelerate identification. As most individuals with AD are not evaluated by specialists, accurate and usable information about the place of biomarkers in the diagnosis and treatment of cognitive impairment must reach primary care With growing interest in the promise of non-invasive biomarkers to improve detection, differentiation, and diagnosis of AD, new research is needed to generate real-world evidence about their performance across populations, how to interpret results, and how best to use them in patient management. Effective educational strategies are needed to disseminate high-quality evidence that engages primary care and healthcare delivery systems in implementing optimal clinical pathways. More detailed learnings for successful care pathway implementation will be shared.

Identification of early-stage Alzheimer's disease (AD) remains a challenge due to limited specialist availability, diagnostic access, disease awareness, and cultural factors. Blood-based biomarkers (BBBM) could play a critical role in the identification and referral of patients suspected of AD to specialty care. A multidisciplinary AD Biomarker Task Force was convened to evaluate current biomarker use cases, define an optimal biomarker-enabled AD diagnostic care pathway, and understand factors impacting adoption. The Task Force identified opportunities to support biomarker-enabled AD diagnostic care pathway adoption, including streamlining risk assessment and screening by leveraging digital tools, activating primary care providers through education, generating data to expand applicability to diverse populations, and advocating for aligned policies and quality measures. Adoption of BBBMs in the primary care setting will be critical to improve early AD detection. However, challenges to pathway adoption persist and will require action from clinicians, payers, policy makers, and patients to address. Highlights:Blood-based biomarkers can streamline the identification of AD in primary care.Future biomarker-enabled diagnostic care pathways will leverage digital assessments.Education, data generation, and policy advocacy are vital to encourage BBBM use.Implementation of AD care pathways requires the activation of diverse stakeholders.

BACKGROUND:Shelter-in-place orders during the COVID-19 pandemic created unmet health-related and access-related needs among older adults. We sought to understand the prevalence of these needs among community-dwelling older adults.METHODS:We performed a retrospective chart review of pandemic-related outreach calls to older adults between March and July 2020 at four urban, primary care clinics: a home-based practice, a safety net adult medicine clinic, an academic geriatrics practice, and a safety net clinic for adults living with HIV. Participants included those 60 or older at three sites, and those 65 or older with a chronic health condition at the fourth. We describe unmet health-related needs (the need for medication refills, medical supplies, or food) and access-related needs (ability to perform a telehealth visit, need for a call back from the primary care provider). We performed bivariate and multivariate analyses to examine the association between unmet needs and demographics, medical conditions, and healthcare utilization.RESULTS:Sixty-two percent of people had at least one unmet need. Twenty-six percent had at least one unmet health-related need; 14.0% needed medication refills, 12.5% needed medical supplies, and 3.0% had food insecurity. Among access-related needs, 33% were not ready for video visits, and 36.4% asked for a return call from their provider. Prevalence of any unmet health-related need was the highest among Asian versus White (36.4% vs. 19.1%) and in the highest versus lowest poverty zip codes (30.8% vs. 18.2%). Those with diabetes and COPD had higher unmet health-related needs than those without, and there was no change in healthcare utilization.CONCLUSIONS:During COVID, we found that disruptions in access to services created unmet needs among older adults, particularly for those who self-identified as Asian. We must foreground the needs of this older population group in the response to future public health crises.

A diagnosis of dementia impacts all other comorbid conditions and areas of patient care. Yet, in primary care settings, dementia is often underdiagnosed and misdiagnosed due to competing clinical concerns. Delayed diagnosis and care of dementia can lead to more rapid cognitive decline, and increased hospitalizations, health care costs, and mortality. The objective of this work was to understand the challenges and successful approaches among primary care providers working in safety net settings when caring for patients with dementia and co-existing chronic conditions. Qualitative interviews focused on practices and challenges diagnosing and caring for patients with dementia, challenges related to comorbidities, needs for practice improvement, and successful approaches. Data was analyzed using thematic analysis. We interviewed primary care physicians (n = 29) and primary care nurse practitioners (n = 6) based in California safety net settings in the SF Bay Area, Central Valley, and Southern California. PCPs identified the following comorbidities as most challenging to co-manage with dementia: mental illness (depression/anxiety), hypertension, diabetes, heart disease, stroke, pain, substance use, and trauma. Most PCPs made a distinction between poorly controlled and well-controlled chronic conditions. Challenges identified included: difficulty differentiating symptoms of dementia from other conditions, medication management and adherence; time constraints when making decisions about prioritizing acute comorbidities or dementia; need for family/caregiver involvement; and challenges controlling comorbid conditions when dementia is present. Successful approaches included: using team-based care and targeted referrals (e.g. social work, community health workers, geriatrics); the importance of familiarity and long-term relationships with patients; finding ways to involve family members; and simplifying visits, care plans, and communication. PCPs face difficulties when providing care to patients with dementia and comorbid conditions, but they also identified opportunities for improvement by sharing successful approaches used in challenging healthcare settings. Findings can help shape intervention development to better support PCPs.

Importance Although the barriers to dementia care in primary care are well characterized, primary care practitioner (PCP) perspectives could be used to support the design of values-aligned dementia care pathways that strengthen the role of primary care. Objective To describe PCP perspectives on their role in dementia diagnosis and care. Design, Setting, and Participation In this qualitative study, interviews were conducted with 39 PCPs (medical doctors, nurse practitioners, and doctors of osteopathic medicine) in California between March 2020 and November 2022. Results were analyzed using thematic analysis. Main Outcomes and Measures Overarching themes associated with PCP roles in dementia care. Results Interviews were conducted with 39 PCPs (25 [64.1%] were female; 16 [41%] were Asian). The majority (36 PCPs [92.3%]) reported that more than half of their patients were insured via MediCal, the California Medicaid program serving low-income individuals. Six themes were identified that convey PCPs’ perspectives on their role in dementia care. These themes focused on (1) their role as first point of contact and in the diagnostic workup; (2) the importance of long-term, trusting relationships with patients; (3) the value of understanding patients’ life contexts; (4) their work to involve and educate families; (5) their activities around coordinating dementia care; and (6) how the care they want to provide may be limited by systems-level constraints. Conclusions and Relevance In this qualitative study of PCP perspectives on their role in dementia care, there was alignment between PCP perspectives about the core values of primary care and their work diagnosing and providing care for people living with dementia. The study also identified a mismatch between these values and the health systems infrastructure for dementia care in their practice environment.

BACKGROUND Hospitalizations by patients who do not meet acute inpatient criteria are common and overburden healthcare systems. Studies have characterized these alternate levels of care (ALC) but have not delineated prolonged (pALC) versus short ALC (sALC) stays. OBJECTIVE To descriptively compare pALC and sALC hospitalizations-groups we hypothesize have unique needs. DESIGNS, SETTINGS, AND PARTICIPANTS A retrospective study of hospitalizations from March-April 2018 at an academic safety-net hospital. MAIN OUTCOME AND MEASURES Levels of care for pALC (>3 days) and sALC (1-3 days) were determined using InterQual©, an industry standard utilization review tool for determining the clinical appropriateness of hospitalization. We examined sociodemographic and clinical characteristics. RESULTS Of 2365 hospitalizations, 215 (9.1%) were pALC, 277 (11.7%) were sALC, and 1873 (79.2%) had no ALC days. There were 17,683 hospital days included, and 28.3% (n = 5006) were considered ALC. Compared to patients with sALC, those with pALC were older and more likely to be publicly insured, experience homelessness, and have substance use or psychiatric comorbidities. Patients with pALC were more likely to be admitted for care meeting inpatient criteria (89.3% vs. 66.8%, p < .001), had significantly more ALC days (median 8 vs. 1 day, p < .001), and were less likely to be discharged to the community (p < .001). CONCLUSIONS Patients with prolonged ALC stays were more likely to be admitted for acute care, had greater psychosocial complexity, significantly longer lengths of stay, and unique discharge needs. Given the complexity and needs for hospitalizations with pALC days, intensive interdisciplinary coordination and resource mobilization are necessary.

The population of people experiencing homelessness (PEH) is aging; Half of PEH are now 50 years old or older. Cognitive impairment among PEH is thought to occur earlier, at higher prevalence, and progress faster than in the general population. Homelessness and associated marginalized conditions pose substantial barriers to care of people with cognitive impairment or dementia. We examined the prevalence of cognitive impairment, dementia, and clinical factors associated with these diagnoses among PEH seen between 7/1/2019-5/31/2022 in a San Francisco safety net clinic. Medical record data for those who accessed services targeting homeless adults was retained for analysis. We analyzed the data using chi-squared, T-tests, and adjusted regression on select variables. Among 8,387 adults who experienced homelessness, 326 (3.9%) had a diagnosis indicating cognitive impairment or dementia. Of these, the majority (303, 92.9%) had non-specific diagnoses, such as “cognitive impairment” (207, 2.5%), problems with “cognitive function” (19, 0.2%), or “memory issues” (77, 0.9%). 114 had specific diagnoses such as dementia (74, 0.9%), Alzheimer’s (6, 0.1%), or neurocognitive disorder (34, 0.4%). Some diagnoses overlapped (e.g. “cognitive impairment” and “dementia” were coded for one patient.) More of those with dementia or cognitive impairment had HIV, diabetes, hypertension, depression and/or anxiety, alcohol-use disorder, and prior TBI. Those with dementia/cognitive impairment were more likely to be male and older (Table 1). More of those with dementia/cognitive impairment were white, Black, or Asian/Pacific Islander, and fewer were Latinx. Since their last clinical encounter, more of those with dementia/cognitive impairment died. In adjusted regression, the difference in hypertension, depression/anxiety, alcohol use disorder, TBI, gender, and mortality remained significant (p<0.05). Prevalence of dementia and cognitive impairment in this patient cohort is lower than has been previously estimated in PEH (4% vs up to 25%). Non-specific diagnoses were more commonly recorded, suggesting under-identification and under-diagnosis in non-research conditions. Those with dementia or cognitive impairment diagnoses had more chronic disease and psychiatric illness, and higher mortality than those without any diagnosis. Better identification of those with cognitive impairment and dementia among PEH can help define areas of focus in the care of these marginalized individuals.

Background: Cognitive impairment, including dementia, is frequently under-detected in primary care. The Consortium for Detecting Cognitive Impairment, including Dementia (DetectCID) convenes three multidisciplinary teams that are testing novel paradigms to improve the frequency and quality of patient evaluations for detecting cognitive impairment in primary care and appropriate follow-up. Objective: Our objective was to characterize the three paradigms, including similarities and differences, and to identify common key lessons from implementation. Methods: A qualitative evaluation study with dementia specialists who were implementing the detection paradigms. Data was analyzed using content analysis. Results: We identified core components of each paradigm. Key lessons emphasized the importance of engaging primary care teams, enabling primary care providers to diagnose cognitive disorders and provide ongoing care support, integrating with the electronic health record, and ensuring that paradigms address the needs of diverse populations. Conclusion: Approaches are needed that address the arc of care from identifying a concern to post-diagnostic management, are efficient and adaptable to primary care workflows, and address a diverse aging population. Our work highlights approaches to partnering with primary care that could be useful across specialties and paves the way for developing future paradigms that improve differential diagnosis of symptomatic cognitive impairment, identifying not only its presence but also its specific syndrome or etiology.

This Editorial comments on the article by Zietlow et al . in this issue.

BACKGROUND AND OBJECTIVES:Even before the COVID-19 pandemic, older adults with cognitive impairment living alone (an estimated 4.3 million individuals in the United States) were at high risk for negative health outcomes. There is an urgent need to learn how this population is managing during the pandemic. RESEARCH DESIGN AND METHODS:This is a qualitative study of 24 adults aged 55 and older living alone with cognitive impairment from diverse racial/ethnic backgrounds. Participants' lived experiences during the pandemic were elicited via 59 ethnographic interviews conducted over the phone either in English, Spanish, or Cantonese. Using a qualitative content analysis approach, interview transcripts were analyzed to identify codes and themes. RESULTS:Qualitative analysis of transcripts revealed 5 themes: (a) fear generated by the pandemic, (b) distress stemming from feeling extremely isolated, (c) belief in misinformation, (d) strategies for coping during the pandemic, and (e) the importance of access to essential services. DISCUSSION AND IMPLICATIONS:This pandemic put a spotlight on the precarity and unmet needs of older adults living alone with cognitive impairment. Findings underscore the need to expand access to home care aides and mental health services for this population.

Background: Shelter-in-place orders and service disruptions due to the COVID-19 pandemic created a risk of unmet healthrelated needs among older adults and those with disabilities, such as the ability to obtain medications or receive healthcare To mitigate these risks, primary care clinics performed outreach calls to identify and address unmet needs We examined the association with unmet needs and healthcare utilization Methods: Four primary care clinics completed outreach calls, each with differing with at-risk populations: home-based, safety-net adult, academic geriatrics and safety-net HIV Examined needs included medication refills, medical supplies, food insecurity, and telehealth capability Utilization included urgent care, ER visits and hospitalizations, measured 3 months prior and 3 months after the call We also report on COVID diagnosis and death in the 3 months after the outreach call We show descriptive statistics and will use Poisson regression models to examine associations Results: Thus far, we analyzed 165 of 500 total outreach calls Mean age was 84 1, with 18% of patients \u003e95, 71% female, 40% white, 33% Asian, 12% Black, and 15% Latinx Forty five percent had both Medicare and Medi-Cal, 33% had Medicare and supplemental insurance, and 17% had Medicare only Comorbid conditions were frequent: 69% had hypertension, 37% had dementia, 30% had depression Unmet needs and care utilization are presented in Table 1 Conclusion: The pandemic has disrupted health and social care among older adults Evaluation of associations between unmet needs and use of urgent healthcare services can inform future planning during crises to better meet the needs of community dwelling older adults