Primary care based collaborative approach to care management for older adults with dementia

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Care for the growing population of older adults with Alzheimer's Disease and Related Dementias (ADRD) is challenging. Care management programs are a common approach to streamlining care for persons with conditions such as ADRD. Care management programs are typically siloed in individual settings; however, as older adults with ADRD utilize care in many settings, they are often contacted by multiple care management programs. Simultaneous enrollment in more than one care management program (hereafter “simultaneous enrollment”) may paradoxically lead to less coordinated care if the programs do not collaborate. The prevalence and consequences of simultaneous enrollment in ADRD are unclear. This K23 proposal builds upon the candidates' work funded by the Grants for Early Medical/Surgical Subspecialists' Transitioning to Aging Research (GEMSSTAR, R03) to advance understanding of the consequences of simultaneous enrollment and the acceptability and potential design of a primary care-based collaborative approach to care management for older adults with ADRD. Aim 1 will result use a novel linked dataset that includes care management enrollment data from two health systems in Baltimore and statewide hospital and emergency department utilization data to determine whether simultaneous enrollment in care management is: (1) more common among older adults with ADRD and (2) associated with preventable hospital and emergency department use. Aim 2 will use qualitative interviews with four groups of stakeholders (care management program leaders and staff, primary care clinicians and office staff, health information technology experts, older adults with ADRD and their family caregivers) to identify barriers and facilitators to and the design of a primary care-based collaborative approach to care management for older adults with ADRD. Aim 3 will pilot test a primary care based collaborative approach to care management for older adults with ADRD focused on feasibility and acceptability. The proposed research will contribute needed evidence about how to best approach care for older adults with ADRD in the context of population health initiatives such as care management. The candidate is a geriatrician who has already demonstrated a strong track record of academic scholarship with numerous publications and early investigator grants. She has proposed a comprehensive set of training activities that are geared toward her development as a clinician investigator and national leader who informs improvements to care delivery for older adults with ADRD. The project will foster her continued career development in the following ways (1) additional coursework and experience in advanced statistical methods, (2) developing a foundational understanding of bioinformatics, (3) applied experience in intervention design in the context of ADRD care, (4) improving her understanding of population health initiatives. She has assembled an exemplary mentoring team with expertise in the subject area and the relevant research methods and works in a rich research environment with tremendous resources to support her development.