Comprehensive Home-based Dementia Care Coordination for Medicare-Medicaid Dual Eligibles in Maryland
| Status: | Completed |
|---|---|
| Conditions: | Neurology |
| Therapuetic Areas: | Neurology |
| Healthy: | No |
| Age Range: | Any |
| Updated: | 9/2/2018 |
| Start Date: | March 2015 |
| End Date: | November 30, 2017 |
This Center for Medicare and Medicaid funded health care innovation award will implement the
MIND at Home dementia care coordination program (called MIND at Home-Plus) through two
community-based service agencies (Jewish Community Services, Johns Hopkins Home Care Group)
to rapidly improve the ability of 600 dually eligible older adults with dementia in the
Baltimore region to remain at home while improving care quality, enhancing quality of life,
and reducing total health care costs. MIND at Home participants receive an in-home needs
assessment followed by up to 18 months of care coordination aimed at filling unmet needs.
MIND at Home dementia care coordination program (called MIND at Home-Plus) through two
community-based service agencies (Jewish Community Services, Johns Hopkins Home Care Group)
to rapidly improve the ability of 600 dually eligible older adults with dementia in the
Baltimore region to remain at home while improving care quality, enhancing quality of life,
and reducing total health care costs. MIND at Home participants receive an in-home needs
assessment followed by up to 18 months of care coordination aimed at filling unmet needs.
The demonstration project has 3 major tasks which will be implemented in concurrent,
iterative phases: (1) implement MIND-Plus in 2 community-based health service agencies to
rapidly improve the ability of 600 community-living dually eligible older adults with AD in
the Baltimore region to remain at home while improving care quality, enhancing quality of
life, and reducing total health care costs associated with institutional care or
hospitalization; (2) develop a replicable model for nationwide diffusion of the MIND program
through a web-based certification package designed to prepare for implementation, build
work-force capacity through training certification modules, and provide automated
self-monitoring and quality improvement tools; and (3) develop and test a detailed payment
model that takes a blended approach and includes provider care management fees with provider
performance incentives from division of shared savings.
The investigators hypothesize that the MIND-Plus dementia care coordination program will (1)
rapidly improve health & care quality and reduce total health care costs among
Medicare-Medicaid dually eligible community-living older adults with AD, (2) drive health
care system transformation by creating a new CMS financed benefit that would shift the hub of
dementia care coordination to well-trained, dementia competent, interdisciplinary teams based
in community health agencies, (3) achieve a sustainable payment model that produces
significant net savings and incentives provider performance. This "shovel ready"
community-based model is expected to improve outcomes within 6 months and save an estimated
net-saving of $12.5 million by over 3 years.
iterative phases: (1) implement MIND-Plus in 2 community-based health service agencies to
rapidly improve the ability of 600 community-living dually eligible older adults with AD in
the Baltimore region to remain at home while improving care quality, enhancing quality of
life, and reducing total health care costs associated with institutional care or
hospitalization; (2) develop a replicable model for nationwide diffusion of the MIND program
through a web-based certification package designed to prepare for implementation, build
work-force capacity through training certification modules, and provide automated
self-monitoring and quality improvement tools; and (3) develop and test a detailed payment
model that takes a blended approach and includes provider care management fees with provider
performance incentives from division of shared savings.
The investigators hypothesize that the MIND-Plus dementia care coordination program will (1)
rapidly improve health & care quality and reduce total health care costs among
Medicare-Medicaid dually eligible community-living older adults with AD, (2) drive health
care system transformation by creating a new CMS financed benefit that would shift the hub of
dementia care coordination to well-trained, dementia competent, interdisciplinary teams based
in community health agencies, (3) achieve a sustainable payment model that produces
significant net savings and incentives provider performance. This "shovel ready"
community-based model is expected to improve outcomes within 6 months and save an estimated
net-saving of $12.5 million by over 3 years.
Inclusion Criteria:
- diagnosis of dementia
- community living
- has identified study partner willing to participate
- english speaking
Exclusion Criteria:
- situation at time of referral is a medical or mental health crisis
- they plan to move out to another area or into a residential care facility in the next
6 months
- they are currently on hospice.
We found this trial at
1
site
3400 N Charles St
Baltimore, Maryland 21205
Baltimore, Maryland 21205
410-516-8000
Principal Investigator: Quincy M Samus, PhD, MS
Phone: 410-550-6744
Johns Hopkins University The Johns Hopkins University opened in 1876, with the inauguration of its...
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