Implementation of the Care Ecosystem Training Model for Individuals With Dementia in a High-risk, Integrated Care Management

Completed · Not applicable

Conditions studied: Dementia, Alzheimer Disease

In brief

There is growing need for to provide high quality care for persons living with dementia (PLWD) and provide support for care partners in the primary care setting. The Care Ecosystem model is a telephone-based dementia care program that provides standardized, proactive, personalized, and scalable support and education for care partners. The Care Ecosystem model has demonstrated an improvement in patient quality of life, reduced unnecessary healthcare expenditures, and a decrease in care partner burden and depression. In this pilot the investigators will assess the feasibility of implementing and measuring outcomes of an adapted Care Ecosystem training model for primary care nurse managers serving a diverse panel of PLWD and their care partners in primary care practices participating in the Mass General Brigham healthcare system's Integrated Care Management Program in Boston, MA. The study team will leverage the Mass General Brigham electronic medical record to determine the feasibility of collecting the primary clinical outcome defined as emergency department visits among the PLWD cared for by the primary care practices. The investigative team will also assess the feasibility of implementation, number of contacts between nurse care managers and care partners, and documented advance care planning.

Key facts

Study ID

NCT04556097

Run by

Mclean Hospital

People needed

524

Starts

2020-12-15

Expected to finish

2021-11-03

Last updated by the study team

2025-08-05

Who can join

Age: 65 and older. Sex: any. Healthy volunteers: accepted.

You may qualify if…

• Medicare beneficiary aligned to the Partners Medicare ACO
• ICD-10 diagnosis code consistent with dementia in Medicare claims between August 1, 2019 and July 31, 2020 (excluding diagnoses for diagnostic testing services)
• Actively engaged in care management services with a nurse care manager enrolled in the study

You may not qualify if…

• Permanent resident of long-term care or deceased at the start of the study

Where it is running

• Mass General Brigham — Somerville, Massachusetts, United States

Full record on ClinicalTrials.gov

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