S2-05-01: Beyond primary care: Improving the impact and reach of collaborative care models for Alzheimer's disease

Abstract

Most older adults with Alzheimer's disease are cared for by primary care physicians. Recent collaborative care models demonstrate the capacity to improve the process and outcomes of care in primary care. However, these models still suffer from limited impact and reach. We recently reported the results of a controlled clinical trial that tested the effectiveness of collaborative care for older adults with Alzheimer's disease. All enrolled patients met diagnostic criteria for AD. Intervention patients received collaborative care led by an advanced practice nurse who worked with the primary care physician, the patient's caregiver, and the dementia specialists to provide guideline-level care. Therapies focused on non-pharmacologic management of behavioral disturbances. Treatment protocols were supervised by clinicians with expertise in dementia care and followed standard of care for pharmacotherapy. Usual care patients received a formal diagnosis and education program and referral to community services. We combined clinical trial data from 100 low-income older adults with AD with longitudinal data from an electronic medical record to compare three-year outcomes for mortality and health services use among the experimental groups. The average patient age was 77 and the mean MMSE score among this cohort was 17.5 at baseline. Patients suffered from a high burden of comorbid conditions and less than 20% had a spouse-caregiver. Only 55% of the caregiver's lived with the patient. Although patients in the intervention group (n=55) had significantly better NPI scores at 18 months compared with controls (n-45), we found no difference in 3-year mortality rates (20% v 29%), hospitalization rates (40% v 47%), mean LOS (5.4 v 7), emergency department utilization rate (82% v 78%), Medicaid nursing home rates (9% v. 18%) or mean total Medicaid nursing home days (39 v. 51). Care for older adults with Alzheimer's disease is fragmented across multiple providers and site of care. These patients are high utilizers of acute care services. Collaborative care based in primary care can improve quality of care and behavioral disturbances and hold promise for decreasing utilization. However, these interventions will need to be broadened in scope, impact, and reach in order to promote implementation.