AMGA
Implementation of MIND at Home Program in Primary Care for People Living with Dementia
Health Care Systems
- McFarland Clinic
- CommonSpirit
Dr. Ciemins is a health services research scientist and vice president of Research and Analytics at the American Medical Group Association (AMGA). In her role, she focuses on data-driven population health improvement through comparative and predictive clinical analytics. Prior to AMGA, she served for 10 years as director of the Center for Clinical Translational Research at Billings Clinic where her research focused on improving the quality of care and care transitions across a large, geographically disperse service area in the areas of diabetes, hypertension, palliative care, and health IT. Dr. Ciemins’ areas of research interest include chronic disease management, health information and telehealth technology, palliative care, childhood and adult obesity, care transitions, rural health, mental health, and complexity science approaches to behavior change in health care. Dr. Ciemins holds a PhD in Health Services and Policy Analysis from the University of California, Berkeley, an MPH in Population/Family Health, and MA in African Studies from University of California Los Angeles.
RATIONALE: People living with dementia (PLWD) represent some of the highest-need and highest-cost individuals living in the community and primary care plays a pivotal in the detection, diagnosis, and delivery of services for this vulnerable patient group. Despite the availability of a range of evidence-based dementia and symptom management approaches, few American PLWD receive adequate care; embedding effective evidence-based interventions and dementia care best practices into primary care settings is needed, but not yet widely done.
OBJECTIVE: To embed and test the feasibility of a novel best practice-based approach, MIND at Home, within primary care to enhance and elevate the role of existing primary care staff to Memory Care Coordinators (MCCs), increase primary care access to interdisciplinary collaborative care, and systematically combine the benefits of clinic-based services with home-based assessment to support family-centered care planning and implementation for PLWD and their care partners.
SETTING: Three primary care clinics in two geographically and demographically diverse integrated health systems.
POPULATION: Community-residing primary care patients with an Alzheimer’s disease and related dementia (ADRD) diagnosis who have at least one caregiver/care partner.
INTERVENTION: MIND at Home is a comprehensive care coordination program that takes an interdisciplinary, collaborative care approach by systematically assessing and addressing a wide range of dementia-care related needs of both PLWD and their care partners that place both at increased risk for poor outcomes. MIND brings a home-based component to what is often exclusively clinic-based care delivery while providing ongoing education designed to build primary care team dementia management capacity through regular interdisciplinary collaboratives with dementia experts.
OUTCOMES: The primary clinical outcome is hospital transfers including admissions, ED visits, and observation stays. Secondary outcomes include overall number of medications, number of anti-psychotic medications, acetylcholinesterase inhibitors and memantine. EHR-based outcomes will be collected pre-, during-, and post-intervention for a total of 7 months.
IMPACT: Embedding a collaborative, best-practice based approach, such as MIND at Home, into primary care is a potentially powerful strategy to organize care, improve quality, reduce costs, and maximize benefit for PLWD.