What is coordinated care?

The chief goal of coordinated care is to develop cost-effective strategies to make health care systems more responsive to the needs of people with complex chronic illnesses such as Alzheimer’s disease.

Current systems often fail to meet those needs. Care is fragmented, with little communication among different professionals providing treatment. Follow-up and monitoring are poorly planned. Health professionals are often rushed, with barely enough time to address the pressing reason for a visit and none left over to provide support, education, or referrals to community resources.

Fragmentation and lack of follow-up, education and support all put chronically ill patients at risk of costly health crises, such as emergency room visits and unplanned hospitalizations.

Coordinated care aims to improve health outcomes, avoid crises and reduce costs by:

• identifying medical, functional, emotional and social needs

• meeting those needs through integration of medical services and education and support of patients and families

• monitoring patients for early signs of problems

Association role

Since 1995, the Alzheimer's Association has partnered with health care organizations to develop, implement and evaluate models of coordinated medical care and supportive services for people with Alzheimer's disease and other dementias.

Several of these partnerships produced the Guidelines and Tools posted below.

The projects discussed here all had care managers to assist with care coordination. Some care managers were based in the partnering health organization, some were in local Alzheimer’s Association chapters, and some were in another community agency.

One indicator of success in these initiatives was the proportion of people with dementia and family caregivers who received Alzheimer’s Association chapter services. To encourage referral and timely use of services, the projects instituted a process in which the health professional asked the person and family for permission to give their names and contact information to the local chapter so the chapter could initiate a relationship.

Guidelines and tools

• Clinical Practice Guidelines for Dementia Care from Kaiser Permanente
  America’s oldest and largest integrated health care organization, with more than 8 million members in 9 states and the District of Columbia.

• The U.S. Department of Veterans Affairs (VA) provides medical care and other benefits to America’s 25 million living veterans. The Partners in Dementia Care program was an innovative partnership between the VA in upstate New York (VISN 2) and four Alzheimer’s Association chapters in that region.
   Partners in Dementia Care Executive Summary (2 pages)
   Partners in Dementia Care Report (30 pages)
   Partners in Dementia Care Appendices (34 pages)

•  Tools for Early Identification, Assessment and Treatment for People with Alzheimer's Disease and Dementia (40 pages)
  A Publication of the Chronic Care Networks for the Alzheimer’s Disease, a joint initiative of the Alzheimer's Association and the National Chronic Care Consortium.

Partnerships

Medicare HMOs
Medicare provides health benefits to 40 million elderly and disabled Americans. Medicare beneficiaries can choose to enroll in a Medicare HMO or to remain in regular, fee-for-service Medicare.

In the 1990s, the number of Medicare beneficiaries who enrolled in Medicare HMOs increased very rapidly, growing from 1.8 million in 1993 to 6.3 million (16% of all Medicare beneficiaries) in 1999. In 1995, in response to this rapid growth in Medicare HMO enrollment, the Alzheimer's Association began an initiative to improve care for people with Alzheimer's disease and other dementias who are enrolled in Medicare HMOs.

The initiative involved the Alzheimer's Association national office and more than 25 local chapters. It has resulted in strong working relationships between chapters and health care systems and providers in their local communities. It has also provided the Association with valuable information about how to coordinate health care and chapter services and how to improve physician knowledge and practices in dementia care.

Partnership with Kaiser Permanente
Since 1995, 10 Alzheimer's Association chapters have worked with the Kaiser Permanente health care system in their community to test ways to improve care for Kaiser members with Alzheimer's disease and other dementias.

Association chapters in Los Angeles, Cleveland, Denver, Hawaii, Portland, Oregon, Sacramento, San Diego, San Francisco, Albany and Washington D.C. have participated in studies that included training for Kaiser staff about Alzheimer's disease and dementia, increasing referrals from Kaiser to the chapter, and joint efforts to provide information, care consultation, and supportive services for the members and their family caregivers.

Highlight here are three partnerships with the Kaiser Permanente system:

Los Angeles: In 1995, the Alzheimer's Association, Los Angeles began working with Kaiser Permanente in Southern California to develop a partnership to improve care for Kaiser Permanente members with dementia and their family caregivers. Nationwide, this partnership was the first joint venture between a managed care organization and a local Alzheimer's Association chapter. The project provided standardization in the diagnosis and management of the disease. It also created a model for collaboration between a Kaiser Permanente region and a community service organization.

•  Establishing Partnerships Between Managed Care and Aging Service Organizations (143 pages)
  A replication manual that highlights important issues to consider when establishing partnerships; includes lessons learned and useful tools. The manual is based on the Alzheimer’s Association-Kaiser Permanente Metropolitan Los Angeles Dementia Care Project.

Cleveland: The Cleveland Alzheimer's Managed Care Demonstration began with a premise that "by initiating contact with individuals with memory problems and their families, Alzheimer's Association Care Consultants will help them address current and future caregiving challenges, thus averting more costly and stressful crises". Over the study period, 210 memory impaired Kaiser members and their families were enrolled. The results testify to the multifaceted impact of the Alzheimer's Association care consultation during just one year of a family's caregiving journey. Not only was patient utilization impacted, reducing use of hospital and emergency room services, but also both patient and caregiver well-being and relationship strain improved.

San Francisco and Albany, NY: In 1996, the Alzheimer's Association launched the Chronic Care Networks for Alzheimer's Disease (CCN/AD) project in partnership with the National Chronic Care Consortium (NCCC). The project's intent is to implement and evaluate a model of coordinated primary and acute health care and supportive services for people with Alzheimer's disease and dementia. In six sites across the country, Alzheimer's Association chapters, and local managed care organizations or other integrated health care systems are working together to implement the project model and improve the care provided for people with these conditions. Once again, Kaiser Permanente has been a major player. Two of the six sites involved a Kaiser health care system - San Francisco and Troy/Albany, NY.

Kaiser Permanente Dementia Care Program
Using ideas and tools developed through these partnerships and other projects conducted by Kaiser Permanente health systems, the Kaiser Permanente Care Management Institute (KP-CMI) developed its Dementia Care Program. This program includes guidelines and recommendations on how dementia care should be provided to Kaiser members. The new program is an informational resource only and is not a substitute for clinical judgment based on the individual needs of patients.

The program includes:

• Nine "key principles" on diagnosing and caring for patients with dementia and support for their caregivers. These principles include early identification and diagnosis, connecting caregivers to vital community resources, developing a care plan and monitoring and adjusting medication use.

• Measures for assessing care performance and progress in caring for people with dementia.

• Valuable forms, tools and lists of resources that will help care providers implement the guideline's recommendations.