Barbara G. Vickrey, MD, MPH

 To analyze whether types of providers and frequency of encounters are associated with higher quality of care within a coordinated dementia care management (CM) program for patients and caregivers.

 Secondary analysis of intervention-arm data from a dementia CM cluster-randomized trial, where intervention participants interacted with healthcare organization care managers (HOCMs), community agency care managers (CACMs), and/ or healthcare organization primary care providers (HOPCPs) over 18 months.

Encounters of 238 patient/caregivers (dyads) with HOCMs, CACMs, and HOPCPs were abstracted from care management electronic records. The quality domains of assessment, treatment, education/support, and safety were measured from medical record abstractions and caregiver surveys. Mean percentages of met quality indicators associated with exposures to each provider type and frequency were analyzed using multivariable regression, adjusting for participant characteristics and baseline quality.

 As anticipated, for all 4 domains, the mean percentage of met dementia quality indicators was 15.5 to 47.2 percentage points higher for dyads with HOCM-only exposure than for dyads with none (all 

 <.008); not anticipated were higher mean percentages with increasing combinations of provider-type exposure—up to 73.7 percentage points higher for safety (95% confidence interval 65.2%-82.1%) with exposure to all 3 provider types compared with no exposure. While greater frequency of HOCM-dyad encounters was associated with higher quality (

 <.04), this was not so for other provider types.

HOCMs’ interactions with dyads was essential for dementia care quality improvement. Additional coordinated interactions with primary care and community agency staff yielded even higher quality.

A successful dementia care management program providing high-quality dementia care to patients and family caregivers required care managers (nursing or social work background) trained to use dementia care management tools and protocols to yield substantial quality-of-care gains.

		More frequent encounters (in person, by phone, and by mail) with those care managers— embedded within the patient’s healthcare organization&mdash;were also associated with higher care quality.

		 Interactions with community agency staff and primary care physicians, with whom the algorithms and protocols were purposefully coordinated, were associated with even more meaningful increases in quality.

An estimated 5.4 million people living in the United States have Alzheimer disease (AD),

a number expected to increase 50% over the next 2 decades. The devastating effects of AD and other dementias impact an additional 15 million people who engage as informal family caregivers.

 Because of accumulating functional disabilities and higher mortality, the need for healthcare delivery system supportive structures to assist patients and families is enormous. Several randomized controlled trials using coordinated care dementia management have provided strong evidence of meaningful health benefi ts for patients with dementia and for informal caregivers compared with usual care.

Effective chronic disease care management interventions typically include multiple components with diverse types of healthcare and service providers, which are tested in combination versus usual care.

 These providers include clinicians, community agency staff, and specific care managers interacting with the patient-caregiver dyad, necessitating coordination among these entities. Some programs include nurse practitioners, for example, as care managers within specifi c clinics without built-in structural collaborations with outside agencies.

 Whereas the focus of care management is driven by the clinical condition and is thus similar across programs, the means of delivery by provider type and the intensity of delivery are most likely to vary between programs. Given the complexity of comprehensive care management for dementia, broad translation of new knowledge about effi cacious interventions into diverse practice settings is more likely to occur when complexity is minimized, thereby maximizing sustainability and potentially reducing program costs.

We analyzed how exposure to different care management program provider types, singly or in combination, and exposure intensity were associated with positive effects on care quality with a dementia coordinated care management intervention.

 This structured program emphasized collaborative care planning and enhanced communication across healthcare plan clinicians, social workers who served as care managers within healthcare organizations and community agencies, and the patient-caregiver dyad. We assessed the extent to which exposure to and interactions among these entities were associated with variation in achievement of higher dementia care quality.

The Alzheimer’s Disease Coordinated Care for San Diego Seniors (ACCESS) trial enrolled 408 patients with dementia paired with their informal caregivers (referred to as dyads). The intervention yielded higher receipt of recommended dementia care for 21 of 23 guideline-derived quality of care indicators at 18 months of follow-up, with the mean percentage per dyad of met indicators equal to 63.9% in the intervention arm versus 32.9% in the usual care arm. This cluster-randomized trial was a collaboration of 3 healthcare organizations and 3 community agencies in greater San Diego, California. A task force of clinical champions and community agency leaders met regularly to plan the care program including staffi ng structure and responsibilities, tools, and algorithms. Specially trained dementia care managers (primarily social workers) conducted structured assessments, identifi ed patient and caregiver problems, and further assessed problems to generate a care plan. Dyads were encouraged to participate in care planning. Dementia care managers coordinated and implemented chosen treatment actions and formally linked dyads to medical and community supports and services. The intervention also incorporated strategies for collaborative care planning and enhanced communication across healthcare plans and community agencies, with care coordination, ongoing followup, and decision support (

 Primary care provider education on specifi c problem areas was provided to intervention clinics.

The ACCESS intervention’s Chronic Care Model—based components

 also included a leased Web-based care management software (CaseTrakker; IMA Technologies, Sacramento, California), which was then tailored to the study’s dementia care management protocols. Care managers embedded within the healthcare system as well as those working at study-engaged community agencies (San Diego Alzheimer’s Association, San Diego Caregiver Resource Center, Meals on Wheels San Diego) were trained in and used this software to track and manage case loads, administer assessments, organize care management activities into care plans, generate letters with appropriately merged assessment and care planning data to share with providers, and automate work flow to increase effi ciencies.

Eligible subjects were Medicare recipients who received care from 1 of 3 San Diego area healthcare organizations. Most care recipients (80%) were enrolled in Medicare managed care. Eligibility characteristics and recruitment methods are detailed elsewhere.

 The present analysis includes all 238 caregiver/care recipient dyads in the ACCESS intervention arm, including those who were randomized to care management but were unable to or elected not to receive it.

Sources of Data and Data Abstraction Methods

 All care management communications and encounters were recorded in CaseTrakker. Healthcare organization care managers used this Web-based system to record and guide initial assessments, reassessments, and all follow-up interactions. Community agency care managers (CACMs) accessed this system and recorded their interactions with dyads as well. All communications between care managers were also recorded in CaseTrakker, and every care manager relied upon this system as their electronic record of all individual and shared care management communications and encounters with dyads over the study intervention period.

Data sources we used for assessing dementia care quality were mailed caregiver surveys completed at baseline, 12 months, and 18 months, and abstracted medical records of enrolled patients with dementia.

The CaseTrakker care management database was manually abstracted by 2 professional abstractors using an abstraction tool developed by study investigators.

 All recorded notes from healthcare organization and community care managers were abstracted using on-screen or printed versions of these records. To assess interrater reliability, 10% of records were randomly selected and reabstracted. Agreement for the 3 primary predictor variables ranged from 94.2% to 100%, and kappa statistics for these variables ranged from 0.82 to 1.00.

Independent Variable Creation: Exposures to Types of Providers

The 3 primary independent variables were (1) healthcare organization care manager (HOCM), (2) CACM encounters with dyads, and (3) healthcare organization primary care provider (HOPCP) care management program—related activities. Data elements used to construct all 3 variables were abstracted from the care management software database. (The contents of all documentation in the care management software database were printed or reviewed on-screen during the abstraction process, and a notation that a phone call was made but no one was reached, for example, was not coded as an encounter.)

The HOCM activities coded as encounters for all interactions with dyads included scheduled initial assessments and 6-month reassessments (usually occurring as in-person meetings), as well as follow-up telephone calls, e-mails, and mailed written communications.

The CACM encounters included similar interactions with dyads. Community agency care manager encounters occurred only if there was a referral from the HOCM (which was not counted as a CACM-dyad encounter, since it might not have resulted in a CACM interaction with a dyad). Subsequent encounters between CACMs and dyads were based on CACM assessments and individualized need, and were coded as CACM encounters.

The HOPCP encounters were coded from documented communications between HOPCPs and HOCMs or CACMs, or as HOPCP interactions with dyads that were motivated by HOCM/CACM notifi cation. Healthcare organization primary care provider encounters typically occurred after an HOCM assessment, although HOPCPs could contact HOCMs for assistance and if recorded in the database, this is also included as an encounter.

Because of the highly skewed nature of encounter data, we coded these variables as 1/0 for any encounter by either specific care manager or primary care provider type (referred to as exposure) during the care management program duration for that dyad. Numbers of encounters are also coded as continuous integers (0-X) as an intensity measure, quantified as the average number of encounters per month of care management program duration for that dyad.

Dependent Variables: Dementia Care Quality

Four domains of dementia care quality were developed and analyzed. Processes of dementia care quality, drawn from professional society guidelines,

 were previously established by a steering committee of healthcare organization champions, community agency leadership, and ACCESS study team investigators. From these processes, 23 quality-of-care indicators were developed,

 of which 22 are dichotomous and are grouped by content into 4 domains: assessment, treatment, education/support, and safety (

). For each dyad, the mean percentage of met indicators over the follow-up period was calculated for each of the 4 domains. An analogous measure was derived for the 12-month period prior to enrollment (baseline).

All covariate measures, including care recipient and caregiver ethnicity (coded as ethnic minority [Latino, African American, Asian, First nation/Native Alaskan, Native Hawaiian/Pacific Islander] versus white), marital status, care recipient dementia severity (11-item Blessed-Roth Dementia Scale),

 whether the caregiver was living with the care recipient and relationship to care recipient, whether the care recipient had a behavior problem in the past year, and caregiver’s education (coded as at least high school graduate vs less than high school graduate) were reported in the baseline caregiver survey. Caregivers also reported how large a problem it was to get caregiver assistance in the past 6 months (not a problem/did not need caregiving assistance, a small problem, or a big problem) in the baseline caregiver survey. Caregivers reported their own chronic health conditions according to a checklist and an open-ended question

 from which a weighted sum was created (possible range: 0-21).

Data sources were linked by a common ID. Separate multivariable linear regression models were constructed for each of the 4 domains of dementia care quality (dependent variables). Independent variables in each model were provider type exposure, number of months that dyads were followed in the program, baseline quality in that domain, and patient/caregiver characteristics. Pearson correlations between each pair of the independent variables were tested to evaluate possible colinearity (defi ned as correlations greater than 0.55).

Primary predictor variables of exposure were sequentially added to account for all possible exposure combinations for each dyad, starting with HOCM alone, HOCM and HOPCP, HOCM and CACM, and all 3 exposure types occurring together. To account for the complex sample study design, all models were adjusted for healthcare organization site and clustered by clinic using Stata procedures for hierarchical data.

As a sensitivity analysis, we reran all models including only the 154 dyads that were in the program the full 18 months.

Articles

Specifically trained care managers are essential for quality gains from a dementia care management program; even higher quality accrues with coordination across community and primary care.

A Dementia Care Management Intervention: Which Components Improve Quality?

: To calculate intervention costs and the potential cost offset of a care management intervention that substantially improved the quality of dementia care.

: From both a payer perspective and a social planner perspective, we analyzed data from a cluster randomized controlled trial (RCT) evaluating this intervention versus usual care. The RCT included 408 pairs of older adults with dementia and their caregivers. Caregivers were surveyed at baseline, at 12 months, and at 18 months to assess patient healthcare utilization and out-of-pocket costs.

: We calculated fixed and per-patient intervention costs from RCT records. We combined the monthly per-patient costs of healthcare services, informal caregiving, and out-of-pocket costs, and we conducted multivariate analyses comparing this sum (potential cost offset) for intervention versus usual care patients. Covariates included patient age, sex, and baseline costs. We limited the main analysis to patients who survived until the 12-month survey or the 18-month survey.

: The intervention required a start-up cost of $70,256 and mean intervention per-patient permonth costs of $118. There were no significant differences in the mean monthly cost of healthcare and caregiving services for intervention versus usual care patients using the societal perspective (difference of −$555 per month, 

= .28) or the payer perspective (difference of −$219 per month [including nursing home costs], 

= .55; difference of −$256 per month [excluding nursing home costs], 

: Although this analysis of a dementia care management intervention did not demonstrate a significant cost offset, the intervention may represent a worthwhile approach to improving the quality of care and health outcomes for patients with dementia and their caregivers.

This cost analysis of a dementia care management program proven to improve quality and outcomes did not show a definitive cost offset over 18 months but may represent a cost-effective approach to providing high-quality dementia care in managed care settings.

Few programs that demonstrably improved quality of dementia care have been reported.

This program successfully connected patients and caregivers to existing community services, as recommended in guidelines.

This detailed cost analysis from the payer and social planner perspectives provides managed care decision makers with data on fixed and ongoing program costs, as well as on potential reductions in other healthcare and caregiving costs.

Dementia, defined as an acquired persistent impairment in 2 or more cognitive areas (eg, language and memory), is a leading cause of disability in older adults.

 Dementia of the Alzheimer type, the most common variant, affects more than 4 million Americans.

Dementia care represents a substantial expense for healthcare organizations and society, with the combined costs for formal services (inpatient and outpatient medical care) and informal caregiving exceeding $25,000 per patient per year in most studies.

 The overall cost burden will escalate significantly over the coming decades as the American population ages and the prevalence of dementia increases.

Existing practice guidelines for dementia care reflect evidence from randomized controlled trials (RCTs) showing that assistance to caregivers can reduce the severity of patients’ symptoms, decrease the use of acute care services, and delay institutionalization, potentially lowering costs over time.

 Unfortunately, adherence to these  guidelines is variable across health systems.

 Collaborative care management programs emphasize coordinated and comprehensive approaches to improving quality of care. These programs are most effective for diseases such as dementia that are high-volume conditions primarily managed in the outpatient setting, have substantial variability in treatment, and rely on coordination with community agencies for recommended social services.

 Large healthcare organizations,  particularly managed care systems, have an opportunity to implement care management programs for patients with dementia that improve quality of care, reduce the burden on caregivers, and potentially have long-term cost offsets.

In a recent evaluation of an RCT of a care management intervention for dementia, it was found that patient health-related quality of life, caregiving quality, social support, level of unmet caregiving  assistance needs, and adherence to published dementia care guidelines were better for intervention patients compared with patients receiving usual  care.

 Although this intervention substantially and broadly improved the quality of dementia care, health plan administrators need data on start-up costs and cost offsets to weigh the value of such programs. Some or all of the initial financial expenses may be recovered over time if the intervention provides an ongoing net savings (eg, by  reducing the need for costly services such as hospitalizations).

To understand the economics of this intervention, we calculated the associated start-up and annual fixed costs and projected the per-patient variable costs of the intervention operating at full capacity. We hypothesized that, among patients who survived for the entire study period, the costs of healthcare and caregiving services would be lower for patients in the intervention arm compared with patients receiving usual care from both payer and societal perspectives. We also hypothesized that savings associated with the intervention would represent a complete offset of the associated start-up and annual fixed costs, such that budget neutrality would be achieved within several years.

The components of the care management intervention, as well as specific study-related outcomes that included adherence to each of 23 dementia guideline recommendations, have been described previously.

 In brief, patients with dementia receiving services in 18 primary care clinics within 3 healthcare organizations in the San Diego, California, area, together with their informal caregivers, were enrolled in a cluster RCT with an 18-month follow-up. Patient-caregiver dyads in the intervention arm were assigned a care manager, who was trained in the use of Internet-based care management software. The care managers performed a structured home assessment, identified problems, initiated care plan actions, and sent a summary to the primary care physician and other designated providers. Care managers provided ongoing follow-up as needed, with in-home reassessments every 6 months.

Three community agencies collaborated with the participating healthcare organizations to provide specific care services (eg, access to respite care). A physician champion was established within each healthcare organization. At each of the intervention clinics, providers received standardized interactive educational seminars on relevant care issues such as the evaluation of acute behavior changes. Selected intervention tools and documents with more detailed descriptions can be accessed at the Alzheimer’s Disease Coordinated Care for San Diego Seniors Web site (http://www.adc.ucla.edu/access/access.swf). Patients, caregivers, and providers in the usual care group did not receive any of the intervention protocol, and patients received care as usual.

Institutional review boards at the University of California, Los Angeles, and all participating sites approved the study, and informed consent was obtained from all study subjects (or from their proxies). Patients were eligible for the intervention if they were at least 65 years of age, enrolled in Medicare (either fee-for-service or managed care plans), had a dementia diagnosis, and had an informal caregiver at least 18 years of age. Potentially eligible patients were identified by a dementia diagnosis code or a cholinesterase inhibitor prescription recorded in administrative claims data. Clinic providers were contacted to confirm each diagnosis and to suggest additional patients as potential participants. Patient-caregiver dyads were enrolled between August 2001 and November 2002. After enrollment, caregivers were surveyed at baseline, at 12 months, and at 18 months. The surveys collected detailed information about patient healthcare utilization, paid and unpaid caregiving hours, costs of paid nonprofessional caregivers, and out-of-pocket expenses in the 6 months before enrollment through 18 months after enrollment.

Within each healthcare organization, clinics were matched by patient volume and subsequently were randomized to either the intervention (9 clinics) or usual care (9 clinics). By the end of the enrollment period, each full-time care manager was managing approximately 50 patient-caregiver dyads. We used this figure to calculate the per-patient variable costs of the intervention, which depended on the scale of the intervention. We used an intent-to-treat framework based on the initial randomization and limited the main analyses to patients with complete utilization data at baseline who survived for the entire study period and had follow-up data at 12 months, 18 months, or both. Patients who were institutionalized during the study period were included in the analyses. We excluded from the main analyses patients who died, as the substantial costs associated with end-of-life care

 might overshadow any cost differences related to the intervention. Although mortality rates did not differ significantly between the intervention and usual care groups at any point during the study,

 we performed sensitivity analyses that included patients who died before the study ended.

Intervention Cost and Potential Cost Offset

In brief, we estimated the cost of the intervention by summing fixed 1-time start-up costs, annual fixed costs, and per-patient variable costs (

). We did not have true cost data for healthcare and caregiving services not directly attributable to the intervention (ie, potential cost offset), but we estimated this information using expenditure data (

). We determined the units of each service utilized by each patient and applied standard unit costs from sources such as the Medical Expenditure Panel Survey and the Centers for Medicare & Medicaid Services. Although we did not include pharmacy costs because sufficiently detailed information was unavailable to us, we performed an ancillary analysis examining the effect of the intervention on the rates of cholinesterase inhibitor use.

We considered 2 different perspectives in calculating the potential cost offset, a “payer” perspective and a “social planner” perspective (

). The payer perspective is limited to the formal costs of care borne by the health plan. We calculated estimates for this perspective under 2 different assumptions with and without the cost of nursing home stays included. The social planner perspective implies that costs and benefits accruing to all members of society are measured.

 This perspective includes not only the formal costs of care but also the opportunity costs associated with informal caregiving, which represent a substantial proportion of the costs of dementia care.

In unadjusted analyses, we compared baseline characteristics and costs of healthcare for the intervention and usual care arms. We used the 

 test for categorical variables and the Wilcoxon 2-sample rank sum test or 2-sample 

 test for continuous variables, depending on their distributions. In ordinary least squares regression analyses, we compared the mean monthly costs of healthcare and caregiving services for intervention and usual care patients who survived the entire 18-month study period and had follow-up data available at 12 months, 18 months, or both. The estimated intervention effect was similar when using square root and log transformations of the dependent variable, so for ease of interpretation we report the results when using the original (nontransformed) cost variable.

To account for the complex sample design, including the clustering of patient-caregiver dyads within clinics, we used generalized estimating equations and adjusted for clinic as the clustering variable using statistical software (STATA 8.2; StataCorp LP, College Station, TX). In addition to the indicator variable for the intervention group versus the control group, we included as covariates patient age and sex, indicators for the healthcare organizations, an indicator of managed care versus fee-for-service insurance, and the patient’s mean monthly costs of healthcare and caregiving services during the 6 months before baseline. The analyses were weighted based on the number of months of follow-up data (maximum, 18 months) available for each subject to increase the influence of data from patients with longer study enrollment and to produce more reliable monthly cost means.27 We conducted 2 sensitivity analyses that included (1) patients with at least 1 follow-up survey regardless of whether they died during the study and (2) patients who survived for the entire study period and had follow-up data at both 12 months and 18 months.

Of 1043 patients initially identified from claims data and contacted about enrollment through their provider, 91 were ineligible, 308 declined to participate, and 236 did not respond, comparable to other quality improvement trials that used registries or claims data to identify potentially eligible subjects for recruitment.

 Four hundred eight patientcaregiver dyads were enrolled (238 in the intervention group and 170 in the usual care group), and all but 1 had complete utilization data at baseline. Survey response rates were 88% at 12 months and 82% at 18 months, excluding 32 deaths in the intervention group and 26 deaths in the usual care group. There were no significant differences in patient or caregiver characteristics (including age, sex, living status, education, marital status, race/ethnicity, dementia severity and duration, and comorbidity) between follow-up survey respondents and nonrespondents. For the main analyses, data were available for 296 of 408 enrolled patients who survived for the entire study period and completed at least 1 follow-up survey. For the sensitivity analyses, data were available for 354 patients who completed at least 1 follow-up survey and for 260 patients who survived for the entire study period and completed surveys at both 12 months and 18 months.

At baseline, the intervention and usual care groups did not differ with regard to demographic and clinical characteristics (

). The mean age was approximately 80 years, and more than half of the patients were female. Approximately three-quarters had dementia of the Alzheimer type, and patients had received a dementia diagnosis on average between 2 and 3 years before study onset. Approximately 77% were in Medicare managed care settings, with the remainder in Medicare fee-for-service arrangements.

There were no significant differences in inpatient or outpatient utilization between the 2 study groups at baseline or at follow-up  (

). At baseline, less than 20% of patients in either group had been hospitalized, and less than 5% of patients overall had been admitted to a nursing home. During the course of follow-up, approximately 30% of patients in each group were hospitalized, and less than 15% were admitted to a nursing home. Although (as previously noted) we could not include medication costs in the cost analyses, there was an increase of approximately 10 percentage points in the use of cholinesterase inhibitors among patients in the intervention group at follow-up versus no change among patients in the usual care group.

The intervention had a fixed start-up cost of $70,256 and annual fixed costs of $24,162 to each of the healthcare organizations regardless of the number of patient-caregiver dyads enrolled (eAppendix A). Assuming that the intervention enrolled 200 patient-caregiver dyads, the variable cost to the healthcare organizations would be $98 per patient per month. Examining the payer perspective with the cost of nursing home stays included, the mean monthly adjusted costs of healthcare and caregiving services during the follow-up period were $219 less for the intervention group compared with the usual care group ($1402 vs $1621 per patient per month), although the difference was not statistically significant (

). Results were similar if the cost of nursing home stays was excluded, with a nonsignificant reduction of $256 in costs for the intervention group ($1119 vs $1375 per patient per month, 

To examine the social planner perspective, we combined the costs accrued by the community agencies with those of the healthcare organizations and included out-of-pocket costs. The fixed start-up cost for each of the 3 community agencies was $1240, with annual fixed costs varying from $4042 to $10,812 across the agencies (eAppendix A). The ongoing mean cost of the intervention was approximately $118 per patient per month for the healthcare organizations and community organizations together. The mean monthly adjusted costs of healthcare and caregiving services during the follow-up period, representing the  potential cost offset, were $555 less for the intervention group compared with the usual care group ($5332 vs $5887 per patient per month), although the difference was again not statistically significant (

). Sensitivity analyses using different inclusion criteria also found no difference in costs between the 2 study arms regardless of whether the social planner perspective or the payer perspective was used. In a 1-sided hypothesis test, we found no evidence that the intervention costs would be less than the cost offset to healthcare organizations as calculated over an 18-month period (

 = .72) (data not shown). Finally, total costs did not differ for patients enrolled in managed Medicare versus fee-for-service Medicare using either analytic perspective.

In this cost evaluation of a dementia care management intervention, we found no evidence of lower costs compared with the costs of usual care at 18 months’ follow-up. However, this intervention has been shown to significantly improve multiple measures of dementia care quality, as well as patient and caregiver outcomes, and may represent a cost-effective approach to improving quality of care even if it is not cost saving.

 and the American Association for Geriatric Psychiatry

 have published guidelines advocating the increased use of comprehensive dementia care strategies. The intervention may be attractive to healthcare organizations that prioritize improving adherence to these guidelines.

We are unaware of any prior cost analyses of dementia care management interventions that were designed to simultaneously target both healthcare and community settings. The Medicare Alzheimer’s Disease Demonstration and Evaluation project examined the effect of case management and collaboration with community organizations, but not health plans, on  formal costs of care.

 The total cost of the project reached budget neutrality at only 1 of 8 sites. The Resources for Enhancing Alzheimer’s Caregivers Health II home-based intervention reported a cost of $5 for each hour of informal caregiving time saved by the intervention.

 The present study adds to the literature by providing cost estimates on a more comprehensive care management intervention that, on average, doubled rates of adherence to 23 indicators of dementia care quality and improved patient and caregiver outcomes.

The likelihood of similar cost estimates if our intervention was replicated in other settings depends on several assumptions, particularly the enrollment of 200 patient-caregiver dyads within a system to achieve full operating capacity. In our study, this enrollment level was reached after 15 months, but delayed or limited enrollment in other settings would increase the per-patient variable costs. Replicating the recruitment approach used in this randomized trial, in which potential participants were identified based on case-finding strategies such as a registry or an administrative database and were then approached and automatically offered the opportunity to enroll, would help to ensure adequate enrollment rather than relying solely on referrals triggered by “crisis” situations.

Given the intervention start-up cost of approximately $75,000, whether managed care organizations ultimately adopt this approach will depend on the existing cost structure of dementia care overall, as well as on projected patient turnover and mortality rates. There are several financial obstacles to adopting this type of intervention in managed care, including the  absence of risk sharing for long-term care. Although long-term care is the most costly aspect of dementia care, Medicaid and patient out-of-pocket payments cover two-thirds of the cost.

 Managed care organizations have little financial incentive to invest in quality improvement strategies that may reduce institutionalization, as they are generally not responsible for expenses related to long-term dementia care.

Another financial barrier to the adoption of care management for dementia is a problematic reimbursement system. Although dementia is a contributing factor to many hospital admissions and increases the cost of inpatient and outpatient care,

 it is rarely recorded as a primary or secondary diagnosis.

 This is related in part to the Centers for Medicare & Medicaid Services—hierarchical condition category model, which does not include dementia as a condition that upweights risk-adjustment factors to further increase reimbursement.

 Until the reimbursement system for dementia care is restructured to provide appropriate reimbursement for patient behavior and safety assessments and for caregiver education, managed care organizations may be reluctant to provide these types of comprehensive services.

Our study has several limitations, including the lack of true cost data for healthcare and caregiving services. We used information on self-reported utilization and expenditures and mean benchmark pricing to estimate this information. In addition, patients and caregivers were well educated and predominantly white and had a usual source of care, which may limit generalizability to settings that include large minority populations with less access to care. Enrolled patients were primarily cared for at home, and these cost estimates do not apply to permanently institutionalized patients. Finally, because we did not have data on medication costs other than out-of-pocket expenditures, we were unable to reliably estimate the per-patient cost for prescription medications.

In summary, this cost analysis of a dementia care management intervention did not demonstrate a significant cost offset. However, given its positive effects on outcomes, the intervention may represent a worthwhile approach to improving the quality of dementia care and health outcomes for persons with dementia. Healthcare organizations should evaluate the potential of dementia care management as a means of promoting evidence-based practices and ensuring the best possible outcomes for patients with dementia and their caregivers.

: Department of Medicine (OKD, SLE, JC) and Department of Neurology (SDV, BGV), University of California, Los Angeles, Los Angeles, CA.

: This study was supported by the California HealthCare Foundation (contract 99-3020), based in Oakland, CA; the State of California Department of Aging (contract IG-0001-22); the State of California Department of Health Services Alzheimer’s Disease Education Initiative; and the State of California Department of Public Health (contract 06-55314) for the University of California, Los Angeles Alzheimer’s Disease Research Center. Dr Duru was supported by the National Institute of Aging (AG028748), through the University of California, Los Angeles Older Americans Independence Center.

: The authors (OKD, SLE, SDV, JC, BGV) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

: Concept and design (SLE, JC, BGV); acquisition of data (SLE, SDV, JC, BGV); analysis and interpretation of data (OKD, SLE, SDV, BGV); drafting of the manuscript (OKD, SDV, BGV); critical revision of the manuscript for important intellectual content (OKD, SLE, JC, BGV); statistical analysis (SLE, SDV); provision of study materials or patients (JC, BGV); obtaining funding (BGV); administrative, technical, or logistic support (BGV); and supervision (BGV).

: O. Kenrik Duru, MD, MSHS, Department of Medicine, University of California, Los Angeles, 911 Broxton Plz, Los Angeles, CA 90024. E-mail: kduru@mednet.ucla.edu.

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 Informal costs of dementia care estimates from the National Longitudinal Caregiver Study. 

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A dementia care management program proven to improve quality and outcomes showed a statistically nonsignificant cost offset (both payer and societal perspectives) over 18 months.

Cost Evaluation of a Coordinated Care Management Intervention for Dementia

 To improve quality of dementia care in a KaiserPermanente service area through rigorous dissemination of practiceguidelines and social worker support for physicians andpatients.

 Pre-post design with practice behavior changeassessed by medical record review, and provider and caregiver satisfactionwith care assessed by surveys.

 A diagnostic guideline and later a managementguideline were adopted for use by Kaiser Permanente physicians inmetropolitan Los Angeles. Physicians received training based onthe guidelines, and social workers provided ancillary support.Eighty-three community-dwelling dementia patients and their caregiverswere referred to the project by primary care physicians andthen were assessed and followed by social workers. Data wereabstracted from medical records to determine whether these interventionsled to improved quality of care as indicated by adherenceto key care processes derived from the adopted dementia guidelines.Chi-square and t tests were applied to compare guidelineadherence and satisfaction rates before and after the interventions.

 Compared with baseline, higher rates of provider andcaregiver satisfaction with Kaiser's system of dementia care werefound at the postintervention follow-up. There also were significantlyhigher rates of adherence to several practiceguidelineâ€“based quality measures: assessment of cognitive status;referrals to the Alzheimer's Association; and assessments of activitiesof daily living, decision-making capacity, depression, and wanderingrisk.

 Quality of primary care for people with dementiacan be improved through guideline implementation with caremanagement support by social workers.

Healthcare organizations are being challenged tocare for the growing number of older adults withchronic health conditions. Dementing diseases,such as Alzheimer's disease, vascular dementia, andother associated disorders, present particular challengesbecause there are strong social and behavioralcomponents to disease management. Physicians play acentral role in assessment, diagnosis, and treatment;but much of the management for noninstitutionalizedindividuals is done by families with the support of socialwork care managers and community resource organizations.Furthermore, primary care physicians are dailyfaced with a broad range of disorders and are challengedby dementia patients, who may compensate for cognitivelosses with retained social skills during the briefoffice visit.

Research suggests that Alzheimer's disease is neitherwell recognized nor systematically diagnosed.

 physicians diagnoseas few as 50% of dementia cases. Focus groups of primarycare physicians from 3 geographic areas found significantbarriers to the recognition and formal diagnosisof dementia. Physicians reported difficulty in recognizingpossible dementia. Many reported that they reliedon families to bring the disease to their attention. Therealso was a prevalent viewpoint that a formal diagnosticevaluation (including a comprehensive clinical historyand mental status examination, laboratory referrals torule out treatable conditions, and other procedures) isnot always necessary.

Yet delay in diagnosis also means delay in treatment.The last 10 years have seen approval of several medicationseffective in slowing progression of Alzheimer's disease,the most common type of dementia in people withmild or moderate cognitive impairment.

 Furthermore,people with undiagnosed dementia and their familiesare less likely to gain access to supportive services thatcan ameliorate caregiver burden and perhaps delayinstitutionalization.

Clinical practice guidelines have been developed andpromoted as tools for improving dementia care.

However, practitioners often are not familiar with theseguidelines; and even when disseminated broadly, theguidelines are not implemented uniformly.

Managed care organizations offer some unique possibilitiesfor quality improvement in dementia care. Theyprovide the communication lines for dissemination ofguidelines. Their accreditation is dependent on adoptionand implementation of guidelines-based qualityimprovement projects.

 Capitated payments can beused creatively to bring in the services of less expensiveprofessionals that may reduce costs or hold them steadywhile improving quality. A number of pilot projectshave been initiated to improve care for people withdementia in managed care settings 

; one such project,involving a large managed care plan in Los Angeles, isdescribed here.

Overview of Project and Description ofIntervention

In 1995, Kaiser Permanente's Metropolitan LosAngeles Service Area entered into a partnership with theAlzheimer's Association of Los Angeles to assess andimprove the quality of care provided to people withdementia. The Metropolitan Los Angeles Service Area ofKaiser Permanente serves a densely urban and ethnicallydiverse region. It includes 2 major medical centers andseveral satellite clinics. Based on extrapolated demographicestimates,

 up to 5000 people with dementiamay be served by Kaiser Permanente in this region.

The goal of the Dementia Care Project was to improvethe quality of care for people with dementia whileincreasing provider and consumer satisfaction. Thestudy used a longitudinal preintervention/postinterventiondesign, with evaluation data collected by medicalrecord review, caregiver interview, and provider survey.A consensus-based diagnostic practice guideline wasdeveloped by a multidisciplinary panel of KaiserPermanente practitioners and representatives of theAlzheimer's Association's Medical and ScientificAdvisory Board. The disciplines of neurology, psychiatry,geriatrics, family practice, psychology, and socialwork all were represented in the development group.This guideline sought to improve consistency in thediagnostic assessments done at Kaiser Permanente inthis region. The project later adopted a managementguideline published by Cummings et al.

 To implementthese guidelines as part of the Dementia Care Project,the following steps were taken:

 Promotion by Kaiser Permanente's clinical leadership through letters to providers and presentations at meetings.

 Broad dissemination of a laminated pocket version of the diagnostic guideline to all primary care physicians in this service area.

 Annual in-service training for primary care providers that was notable for its inclusion of physician leaders and caregivers as speakers, as well as the participation of a theater troupe that enacted a physician visit and the administration of a mental status examination. The theater troupe was used to increase physician empathy for presenting families. It also was assumed that the novelty of this form of teaching would enhance learning.

 Broad dissemination of a provider "tool kit" that contained the 2 guidelines and a variety of forms and tests of mental status and depression to support physicians as they followed guideline recommendations.

 presentoutlines of the diagnostic and management guidelines used by the Dementia Care Project.

The Dementia Care Projectrelied heavily on social work caremanagers to support this guideline basedquality initiative. Two full-timeprofessionals were trained bythe Alzheimer's Association with a24-hour intensive course followedby 7 months of mentoring via caseconferences. Patients were referredto the social workers by their primarycare physicians. The socialwork care managers provided arange of services in support ofphysicians, including administrationof mental status exams, follow-upwith families on thepsychosocial aspects of care, homevisits, intervention with familiesregarding behavior managementissues, and facilitation of connectionto physicians for treatment ofcomorbid conditions. The caremanagers also provided guideline recommendedservices for familycaregivers, including assessmentsof patients, linkage to services withinKaiser Permanente and in thecommunity, caregiver supportgroups, family education, and ongoingcare management.

In order to participate in theDementia Care Project, the personwith dementia needed to have a primarycare physician in the designatedKaiser Permanente servicearea, have a guideline-based dementiadiagnosis, dwell in the community(not in an institution), and havean involved, nonpaid caregiver. Participants also neededto be referred for participation by their primary carephysicians. Data were collected on 83 persons withdementia and their caregivers. The dementia patientsranged in age from 63 to 93 years (mean age = 80 years).They were 52% male and ethnically diverse (55% AfricanAmerican, 21% Caucasian, 3% Latino, 1% Asian, and 19%other or not specified). This ethnic diversity reflects themembership of Kaiser Permanente in this geographicregion. Initial Folstein Mini-Mental Status Examinationscores

 recorded after the program intervention beganwere available for more than 90% of the patients andranged from 2 to 29 with a mean score of 17. Of the 83participating caregivers, 63% were spouses; 16%, daughters;11%, sons; and 10%, other. Their mean age was 66years. The ethnic breakdown of caregivers was 52%African American, 23% Caucasian, 4% Latino, 4% Asian,1% Native American, and 16% other or not specified.

The study was primarily focused on improving thequality of care for people with dementia in this targetedregion. The following indicators of improved qualitywere drawn from the practice guidelines:

 Conducting a cognitive assessment with the Folstein Mini-Mental Status Examination.

, Venereal Disease Research Laboratory/rapid plasma reagin [test forsyphilis], thyroid-stimulating hormone, complete blood count, and selected blood chemistries).

 Referral to the Alzheimer's Association and to the Safe Return Program (for wandering risk) of theAlzheimer's Association.

 Conducting assessments that included activities of daily living, decision-making capacity, depression,and wandering risk.

Barbara G. Vickrey, MD, MPH

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