Telephone- and web-based dementia care provided through centralized hubs and delivered by an interdisciplinary team can improve outcomes for people with dementia and their caregivers.
People with dementia and their caregivers often have to navigate complex care transitions, multiple medications, and siloed care systems and resources to meet dementia-related needs. Dementia progression is associated with high levels of caregiver burden and poor patient quality of life, which can increase the risk of unnecessary acute care use and premature placement in long-term care. This randomized clinical trial tests the effects of the Care Ecosystem, a telephone- and web-based program that provides education, support, and care coordination for people with dementia and their caregivers through an interdisciplinary team consisting of a care team navigator and dementia expert providers (advanced-practice nurse, social worker, and pharmacist). It was piloted in two care systems that served as “hubs” – the University of California, San Francisco (UCSF) and the University of Nebraska Medical Center (UNMC).
Compared with usual care, the Care Ecosystem significantly improved the quality of life and reduced the number of emergency department visits for people with dementia, but did not have an effect on hospitalization or ambulance use. For caregivers, the program was associated with improvements in confidence in performing caregiving tasks at six months and decreases in caregiver burden and depression at six and 12 months.
Health systems and payers can improve outcomes for people with dementia and their caregivers by implementing the Care Ecosystem model. For more detailed implementation information, see the Care Ecosystem Toolkit.