The Dementia Care Ecosystem
The Dementia Care Ecosystem (DCE) is a collaboration between UCSF Medical Center and two other medical centers in Nebraska and Iowa that aims to demonstrate the efficacy of a coordinated care model for dementia patients that includes not only multispecialty medical care, but legal and financial planning as well. Research participants are dementia patients and their caregivers who will be linked to a Care Team Navigator (CTN) who will be responsible for assisting patients and their caregivers with accessing medical and non-medical (e.g. legal) resources to better support their care. A unique feature of this coordinated care model is its use of an online Dashboard (an adjunct to the electronic health record) by the CTNs, the members of the care team, and by patients and their families.
The DCE aims to address both quality of care issues for dementia patients, who too often experience high rates of unnecessary hospitalization and institutionalization that fails to meet their goals of care and diminishes quality of life, as well as cost issues for the health care system. The DCE is funded by a three-year grant from the Center for Medicaid and Medicare Services, which will consider the results of this study in determining whether such services will be covered in the future for Medicaid and Medicare beneficiaries. The Consortium’s role in the project will be to assist UCSF researchers in designing the advance care planning process for patients and training the CTNs in identifying legal and financial needs of the research cohort.