Collaborative Care Coordination Program for Alzheimer's Disease and Related Dementias

Study Overview
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Brief Summary
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This is a randomized, pragmatic clinical trial to evaluate the effectiveness of a collaborative care-coordination program embedded in a health plan for people living with Alzheimer's disease and related dementias (ADRD) and their care partners versus usual care. The study population will include community-dwelling Medicare Advantage members living with ADRD and their care partners. Outcomes will be healthcare utilization outcomes of individuals with ADRD and include emergency department visits, outpatient visits, avoidable emergency department visits, and admission to long-term care facilities.

Official Title
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Collaborative Care Coordination Program for Alzheimer's Disease and Related Dementias (Co-CARE-AD)

Conditions
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Alzheimer's Disease and Related Dementias (ADRD)

Intervention / Treatment
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* Behavioral: Dementia Care Consultation program


Participation Criteria
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Eligibility Criteria
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Community-dwelling Tufts Health Plan Medicare Advantage members with ADRD and their caregivers will be selected to participate in the trial based on the following inclusion/exclusion criteria: Inclusion Criteria (for members with ADRD) Member of Tufts Health Plan Medicare Advantage plan Medical and pharmacy insurance coverage in at least the prior 12 months Have ≥1 ICD-10-CM diagnosis code for ADRD or dispensing for pharmacological treatment for ADRD in the prior 12 months Exclusion Criteria (for members with ADRD): Reside in a nursing home or skilled nursing facility Enrolled in a hospice program Receiving or have received the Dementia Care Consultation program as part of the existing program at the time of enrollment Inclusion Criteria (for caregivers) Age 18 years or older Assume primary responsibility for members

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Dementia Care Consultation program<br>The Dementia Care Consultation program provides an in-depth, personalized service for individuals and families facing ADRD. | Behavioral: Dementia Care Consultation program<br>* The Dementia Care Consultation program uses a telephone-based intervention to provide an in-depth, personalized service for individuals living with ADRD and their care partners. It consists of comprehensive needs assessments, creation and implementation of personalized care plans, monitoring and revising care plans, disease education and support coaching, referrals to community-based organizations for service and support, and access to assistance.<br>|
| No Intervention: Routine Care<br>Members randomized into the control group will receive routine care. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| All-cause emergency department visits | Number of all-cause emergency department visits per member living with ADRD over the 12-month follow-up period. | by 12 months | 
| All-cause emergency department visits | Number of all-cause emergency department visits per member living with ADRD over the 6-month follow-up period. | by 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Outpatient visits | Number of outpatient visits per member living with ADRD over the 12-month follow-up period. | by 12 months | 
| Outpatient visits | Number of outpatient visits per member living with ADRD over the 6-month follow-up period. | by 6 months | 
| Avoidable emergency department visits | Number avoidable emergency department visits (defined using the validated New York University ED visit algorithm) per member living with ADRD over the 12-month follow-up period. | by 12 months | 
| Avoidable emergency department visits | Number avoidable emergency department visits (defined using the validated New York University ED visit algorithm) per member living with ADRD over the 6-month follow-up period. | by 6 months | 
| Admission to long-term care facilities | Number of members living with ADRD with the first admission to long-term care facilities over the 12-month follow-up period. | by 12 months | 
| Admission to long-term care facilities | Number of members living with ADRD with the first admission to long-term care facilities over the 6-month follow-up period. | by 6 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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dementia, informal caregiver, care consultation, care coordination