3D Team Care for Cognitively Vulnerable Older Adults

This study addresses how to achieve better outcomes for cognitively vulnerable
community-dwelling older adults and their families. Cognitive vulnerability means living with
dementia, depression, and/or a recent episode of delirium (the 3Ds). Cognitive vulnerability
in older adults is often overlooked by primary care and hospital-based providers, and
represents a marker for overall vulnerability or frailty often missed when disease-specific
approaches are emphasized in the care for older adults. Such patients often cannot adequately
self-manage their comorbidities. Many studies of older adults and their families have
demonstrated the great burden of living with cognitive vulnerability. The investigators will
test the effectiveness of a team care model focused on the 3Ds (Home Based Care Team) guided
by nurse practitioners with geriatrics expertise. Other team member disciplines will include
pharmacy, social work, occupational and physical therapy, nutrition, and community health
worker. Long-term objectives are to determine whether this care model can become a widely
available approach for improving healthcare systems for older adults with cognitive
vulnerability and their families, while improving outcomes of importance to these patients
and families. A project Steering Committee, including cognitively vulnerable patients and
family caregivers, will provide extensive input into many aspects of the research process.

Inclusion Criteria:

- Evidence of dementia, depression, and/or delirium, based on diagnostic codes found in
medical claims data and based on screening at time of study screening.

- Living in the community, including assisted living facility, at time of randomization

- Plan to live in geographic area for 12 months

- Speak or understand English

- Willing to be randomly assigned to intervention or active comparator group

Exclusion Criteria:

- Diagnosed schizophrenia or bipolar disorder

- Bedbound and non-communicative

- Life expectancy <12 months

- Already enrolled in active comparator program

- For individuals with dementia, family caregiver is unavailable or unwilling to enroll
in study