The Care Ecosystem: Outcomes from an Integrated Healthcare System

AbstractBackgroundThe Care Ecosystem (CE) is a model of dementia care consisting of a multidisciplinary team of nursing, care team navigators (CTNs), and social workers designed to support persons with dementia (PWD) and their caregivers. Developed and tested at the UCSF Memory and Aging Center, the CE has been shown to improve PWD quality of life, reduce emergency department visits, and decrease caregiver depression/burden compared to usual care. We present CE data from a high volume neurology clinic within an integrated healthcare system.MethodA total of 435 patient‐caregiver dyads were enrolled in the CE over a 2.5 year period. Data relating to demographics, dementia severity, caregiver burden, and healthcare utilization were collected at baseline and after one year (n=116). Experience surveys were completed by dyads at 6 and 12 months (n=200). A retrospective review of data captured by RedCap and the electronic medical record was performed.ResultThere was worsening of dementia disease severity (DSRS) and functional impairment (FAQ) over a one year period (figure 1a/b). Both immediate/anticipated caregiver needs (figure 2) and safety concerns (figure 3) decreased over time. For safety, there were particular sizable reduction of caregiver safety concerns for driving (65%), falls (52%), problems getting lost (57%), weight and appetite changes (63%), and medication safety concern (61%) for the PWD. There was a reduction in the number of PWD using >10 medications with the CE (figure 4). The number of ED visits decreased over time whereas hospitalizations increased over the one year (figure 5a/5b). There was a reduction in caregiver depression, difficulty, and burden (6a/b/c). Dyads rated CTNs favorably ranging from 88‐92% of the time.ConclusionOur results suggest that the CE is feasible and effective in an integrated healthcare system setting. Despite worsening of disease state in the PWD, caregiver burden and distress decreased over the one year assessment period, suggesting a favorable impact on caregiver quality of life. PWD and caregivers rated the CTN experience positively. Although these preliminary results favor the CE, further studies are necessary to better understand the impact of the CE on healthcare utilization in integrated healthcare systems.