BANNER ALZHEIMER’S INSTITUTE DEMENTIA CARE INITIATIVE: DESIGN AND IMPLEMENTATION OF THE PILOT PHASE

Despite the prevalence and high cost of care among those with recognized dementia, policy-makers consistently document suboptimal quality and poor outcomes for dementia care in the generalist setting. Primary care physicians lack practice models that accommodate the particular needs of people with dementia, and lack dementia-specific care plans to address recognition of people at high risk, and to guide evaluation, diagnosis, treatment, follow-up, and specialty referral. Our Dementia Care Initiative proposes a strategy for training primary care practices to create a “dementia capable” system that involves, aligns, and incentivizes multiple aspects of a health care system to improve cost of care and clinical outcomes. We describe the pilot phase conducted to assess feasibility of our dementia practice model. The pilot phase took place in two Banner Health primary care practices (one urban, one rural) after a two-year collaborative planning process with workflow engineers and the practice staff. Twenty-three staff were trained to identify all outpatients who were at high risk for having dementia, and to evaluate, diagnose and manage them according to best practice precepts and engage specialists using specific guidelines. These methods will be summarized 420 patients were eligible; 92 (23%) were evaluated. We identified the following barriers to implementation of the pilot practice model: 1) not enough time during visits to accomplish the work; 2) lack of communication between office staff and patients; 3) level of comfort of patient and family; 4) threats to physician-patient trust; 5) complexity of the diagnostic process; and 6) and workflow. The practice model as originally designed was infeasible and has been redesigned to address the important issues identified in the pilot. The revised model, which has been implemented, will be summarized. Once we establish feasibility of the revised practice model, our aim is to modify our health care system to demonstrate clinical and cost effectiveness by ameliorating: 1) recognition and diagnosis of dementia 2) use of dementia-specific medications 3) family satisfaction 4) practitioner satisfaction 5) cumulative hospital days 6) emergency room use 7) use of palliative/hospice care 8) use of inappropriate medications 9) total health care costs.