Transcript Dementia Health Services Research Group University of Washington Welcome to the Neighborhood: Building A Medical Home for Alzheimer’s Disease Soo Borson, MD Professor, Psychiatry and Behavioral Sciences Director, Memory Disorders.

Dementia Health
Services Research
Group
University of
Washington
Welcome to the Neighborhood:
Building A Medical Home for
Alzheimer’s Disease
Soo Borson, MD
Professor, Psychiatry and Behavioral Sciences
Director, Memory Disorders Clinic and Dementia Health Services
Research Group
University of Washington
The Population Imperative
© 3-11 Soo Borson MD
Hebert et al. Neurology 2004
Framework: Caring Systems
• Patients
• Families
• Providers
– Internal medicine/
primary care
– Specialty care
– Social care
• Health systems
– Payers
– Practice organizations
© 3-11 Soo Borson MD
30000
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27000
9000000
24000
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21000
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18000
6000000
15000
5000000
12000
4000000
9000
3000000
6000
2000000
3000
1000000
0
Persons with dementia
Specialists
US Geriatric Specialist Workforce v. Persons with Alzheimer
Dementia
0
1992
1998
projected 2030
Year
Geriatric Medicine
Geriatric Psychiatry
Persons with dementia
http://www.americangeriatrics.org/adgap/ADGAP; Brookmeyer et al, Am J Pub Health 1998
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A Primary Care Report Card
Step
% Complete
Gap
25-60% of cases
(often late)
40-75% of cases
Unknown*
Probably large
Stage-appropriate longrange health care plan
~ 15%**
Large
Care coordination and
collaboration
<20%***
Large
Identification
Open disclosure and
discussion
*< 50% of specialists routinely disclose diagnosis (Raicher et al, Int Psychogeriatrics 2007). ** Wenger et al, Ann Intern
Med 2003; Chodosh et al, JAGS 2007; Borson et al, JGIM 2007. ***Overall estimate based on studies of referrals to
specialists, community resources, Alzheimer’s Association, explicit inclusion of caregivers as partners
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Goals for Redesigning
Primary Dementia Care
• Detect cognitive impairment and diagnose dementia
when it is present
– Eliminate ‘don’t ask, don’t tell’
• Implement chronic care management model
– Dementia is…
• A medical problem caused by specific disease processes
• A target for medical treatment
• A risk factor for other problems
• A (usually) progressive condition with changing, stagespecific management needs
• A major determinant of the context of care
Rationale for Redesign–
Clinical Improvement
• Intervening early improves clinical outcomes for
patients and families1
– Medical treatment
• Donepezil for AD (multiple studies); other cholinesterase
inhibitors
– Psychological/behavioral interventions
– Social and environmental approaches
• Late detection delays secondary and tertiary
prevention
• Earlier detection of dementia makes sense
1 Feil et al for ACOVE team. JAGS 2007.
Rationale for Redesign –
Health and Safety Systems
• Health care
– Delirium in hospital (OR 3.96, 95% CI 1.1-14.2) 1
– Low health literacy/adherence to pre-op instructions (OR
4.0, 95% CI 1.6-9.8) 2
– Deficit in knowledge/management of personal medications3
– Increased hospitalizations for ambulatory care sensitive
conditions (OR 1.8, p < 0.0001) 4
• Public safety
– Driving risk 5
• At home, in the community
– Need for everyday support and assistance 6
1.
Alagiakrishnan et al. JAGS 2007. 2. Chew et al. Am J Surg 2004. 3. Lakey et al. Ann
Pharmacother 2009.
4. Phelan et al (in review). 5. AMA Driver Guide, http://www.amaassn.org/ama/pub 6. Scanlan et al. Am J Geriatr Psychiatry 2007
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Essential Clinical and Administrative Skills
• Timely identification and accurate diagnosis of
cognitive impairment
• Comfort with difficult discussions (e.g. diagnosis,
driving, moving)
• Individualized health care plans for long-term
palliation
• Planned collaboration with caregivers, care
managers and specialists
• Effective use of targeting and management
tracking tools
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Screening for Cognitive Impairment
in Primary Care: RCT
• Four similar clinics in the same network, 2
randomized to screening, 2 to usual practice
• QI framework – patient consent not required
• After vital signs, MA administered the Mini-Cog
– Reliability high
– Refusals rare (<2%)
• N = 524 screened (70% of patients age 65+ in
eligible clinic panels)
• 18% of patients screened positive
Borson S et al JGIM 2007
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Impact of Routine Screening
on Physician Practice
Borson S et al JGIM 2007
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5-Year Follow On
Figure 2: PCP Actions Following Screen Failure
100%
Figure 3: Proportion of Patients with Preventable Acute Care
Episodes or Signs of Cognitive Trouble
100%
90%
90%
80%
80%
70%
70%
60%
60%
50%
50%
40%
40%
30%
74%
37%
28%
30%
24%
20%
20%
13%
10%
10%
0%
0%
eventual dementia diagnosis
any management
at least one ED visit
at least one hospitalization
signs of cognitive trouble in the
chart
In progress:
Comparison with age-matched older adults screening negative 5 years earlier
DeMers S et al. AAGP Annual Meeting, Honolulu, 2009
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Screening for Cognitive Impairment:
Policy Update
• US Preventive Services Task Force
– To update evidence and recommendations this year
• New Medicare benefit: Annual Wellness Visit
(effective Jan 2011)
– Cognitive assessment for early detection
– Personalized health risk assessment (HRA) and
prevention plan
• Incentives
– For patients: no deductible or co-pay
– For physicians: reimbursement equivalent to Level 4
E/M
Fact sheet available on www.alz.org
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Cognitive Assessment in the AWV
• No method specified by CMS
• Acceptable pathways can include
– A screening test
– A question about cognition to the patient and/or family
– A spontaneous patient or family concern about the
patient’s cognition
• Any/all of these pathways will generate a cohort
of patients whose cognitive status should be
further evaluated
• A ‘cognitive visit’ can then be scheduled
What’s in a “Cognitive Visit”?
• Clinical history
–Basis for concern
–First symptoms and signs
–Context of emerging or worsening
–Pattern of progression
–Functional deficits (advanced IADL; IADL, basic
self care ADL)
• Brief neurological exam
–Look for informative signs that suggest etiology
• Confirmatory cognitive testing
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• Risk factor review
– Clinical vascular disease
– Head injuries
– Complications of surgery
– Neurotoxins
– Prescription and OTC medications
– Family history
– Recent hospitalization for acute or critical
illness1 or complex surgical procedure
1 Ehlenbach et al JAMA 2010
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Further Workup
• Use blood tests selectively
– Mainly for treatable confounders and problems related
to effects of dementia
– Few dementias have specific clinical lab indicators
(e.g., HD, HIV, STD)
• Think about neuroimaging
– Few patients require it for diagnosis
• Create a short list of most likely diagnoses
• If you’re not sure, consider specialty consultation
© 3-11 Soo Borson MD
Diagnosis and Disclosure
• Whose responsibility?
– May share with a specialist
• How to do it?
– Patient-centered communication
• Patient’s thoughts, feelings, fears
• Caregiver’s knowledge and concerns
• Physician’s positive affect, direct language, optimism
• When to follow up?
– Anticipate adjustment period
• See a month or less after the diagnosis – check in
• Answer questions, respond to concerns
• Refine management and follow up plan
Boise et al, Gerontol 1999; Iliffe et al, Int J Geriatr Psychiatry 2009; Eccles et al, Int J Behav
Med 2009; Zaleta and Carpenter Am J Alz Other Dem 2010
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Next Steps: Prepare for Chronic Care
MMSE at
Diagnosis
Median Survival
(years)
Maximum Survival (years)
25-30 (very mild)
~7
>15
22-24 (mild)
5.5
>13
18-21 (moderate)
5
~13
≤17 (moderate to
severe)
4
~10
Data on Alzheimer’s disease from Group Health Cooperative ADPR/ACT studies (n = 521).
Larson EB et al. Ann Intern Med 2004. Most other studies find much shorter survival, since
diagnosis occurs later.
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Integrate Dementia
• Palliative philosophy from diagnosis to death, since
dementia is a…




Target of treatment
Modifier of care for other conditions
Prognostic indicator
Risk indicator
• Care is stage-specific
 Components of palliation vary over time
• Care is always a collaboration
– You, the patient, and the family
– A medical dementia specialist, when needed
– A psychosocial care manager, especially at moderate dementia
stages and beyond, or when families are stressed
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Problems Peak at Different Times in
the Course of AD
100%
Cognitive ability
Functional ability
Change with
disease
progression
Behavioral problems
Caregiver time demand/stress
Stage and duration of
usual clinical trials of
antidementia drugs
0
1
2
3
4
5
6
7
8
9
0%
Years from symptom onset
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Stage-Specific Management Concepts
• Very early stage (“MCI”) – educate, support
healthy habits, prevent 2O and 3O
complications, re-evaluate cognition ove4r
time, discuss end of life preferences
• Mild to moderate stage – treat dementia, find
and manage risks, set goals for comorbid
chronic conditions, support good caregiverpatient dynamics and regular medical f/u;
bring secondary family members in; review
end of life wishes; encourage legal review
(DPOA for finances and health care, will,
POLST)
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• Moderate to severe stage – 24 hr supervision
and shared caregiving; prevent injury, expect
behavioral problems, hospitalizations, and
caregiver burnout; review and simplify
medications; surgery only for urgent conditions
with favorable prognosis; update POLST
• Advanced and terminal stage – remove
unnecessary medications; update POLST;
provide hospice/comfort care; with caregivers,
plan for possible terminal event scenarios and
actions appropriate to those – the ‘what if’
conversation
A Comprehensive Framework
for Dementia Care
Diagnosis
and
Staging
Medical Comorbidity and
Risk Management
Patient
Neurobehavioral
Assessment &
Management
Caregiver
Assessment,
Counseling,
Services, and
Planning
© 3-11 Soo Borson MD
Operationalizing the Model
Dementia as a disease
Neuropsychiatric probems
• Diagnose etiology /type
• Recognize depression, demoralization, loss of
confidence, anxiety, agitation, aggression,
psychosis
• Establish stage (cognitive, functional)
• Consider cognitive enhancing medications
• Support adjustment to diagnosis
• Anticipate risks specific to types/stages of
dementia
• Analyze behavioral problems – causes and
consequences
• Implement practical psychosocial interventions
• Train caregivers in hands-on prevention and
management
• Use psychotropic medications selectively
Comorbid medical
conditions and risks
Caregiver issues
• Manage to protect the brain
•Assess and respond to stress and burden
• Identify/implement adherence supports
• Identify caregivers needing community
based services, refer, and follow up
• Address key safety issues (e.g. driving, falls,
injury potential)
• Reframe goals to match prognosis/stage
• Coordinate care with other providers
• Encourage realistic expectations
• Track ongoing needs and gaps
• Provide clinical options to optimize
adjustment across stages
• Palliation at every stage
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Measuring the Quality of Dementia
Care
• Patient and practice level
– ACOVE-3 indicators
– Emerging consensus measures (AMA)
• Health system level
– Uptake of annual wellness visits and their cognitive
assessment component
– Reduction in avoidable hospitalizations and posthospital readmissions
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ACOVE-3 Dementia QIs
•
•
•
•
•
•
•
•
•
•
•
Cognitive and functional screening/evaluation
Medication review and adjustment
Neurological assessment
Lab testing (including HIV if at risk)
Depression screening
Cholinesterase inhibitor discussion
Behavioral symptoms of dementia
Stroke prophylaxis
Caregiver support and patient safety
Driving (state law variations)
Restraint documentation and communication (hospital)
Feil et al. JAGS 2007.
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AMA Consensus Performance Measures
• AMA PCPI with AAN, AGS, AMDA, and APA/AAGP – for
patients with a dementia diagnosis
• 10 domains of quality
–
–
–
–
–
–
–
–
–
–
Dementia staging
Cognitive assessment
Functional status assessment
Neuropsychiatric symptom assessment
Screening for depressive symptoms
Management of neuropsychiatric symptoms
Counseling about safety matters
Counseling about driving
Comprehensive end of life counseling/advance care planning
Caregiver education and support
© 3-11 Soo Borson MD
Setting Up a Care Collaborative
• Dementia Care Manager (DCC) Models
– Callahan et al. JAMA 2006
• Interdisciplinary team led by an advanced practice nurse
– Vickrey et al. Ann Internal Med 2006
• Dementia care guideline model, non-medical care managers
in a primary care setting, involvement of Alzheimer’s
Association and social care agencies
• Primary Care Practice Redesign
– Reuben et al. JAGS 2010
• Six components, internal practice change + Alzheimer’s
Association
• Specialty-Based Medical Home Model
– Lessig et al. JAGS 2006
• Cooperative Dementia Care Clinics and Dimensional
Approach to Care
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Advanced Practice Nurse Model
(Callahan et al.)
Design
• Clinical trial, 153
patients and caregivers
randomized by clinic
• Intervention (n=84) v.
augmented usual care
(n=69)
• Intervention = 8
standardized protocols
for BPSD
Setting
• 10 clinics @ 2 US
university affiliated health
care systems
Outcomes
• 89% triggered ≥ 1
management protocol,
mean of 4 protocols/
patient
• 80% v. 55% prescribed
ChEIs
• 45% v 28% Rx
antidepressants
• Fewer BPSDs (NPI)
• Lower CG distress
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Dementia Care Guideline Model
(Vickrey et al.)
Design
Setting
Outcomes
• Clinics randomized by
• 18 clinics (9
• ↑ adherence to DGLs
practice type, dyads by
physician
• 408 patient-caregiver
dyads (n=238 intervention)
• 23 Dementia Care
Guidelines developed by
consensus across 4
domains (assessment,
treatment, education and
support, safety)
intervention)
• 3 health care
organizations
• 3 community
agencies
(63.9% v 32.9%)
• ↑ care quality for 21/23
DGLs
• ↑ community agency
assistance
• ↑ CG social support &
assistance with unmet
needs
© 3-11 Soo Borson MD
Primary Care Practice Redesign
(Reuben et al)
Design
Setting
• Pre-post intervention study in • 2 large
2 practices
• ACOVE-3 quality indicators
for dementia care
• Intervention components
• Screening (casefinding)
• Dementia-specific clinical data
collection
• EMR prompts
• Pt/family education materials;
referral to local Alzheimer’s
Association
• MD decision support/education
communitybased
physician
practices
Outcomes
•
One of two
practices showed
significant intervention
effects – more
referrals to the local
Alz Assoc (<1/5),
better overall quality
© 3-11 Soo Borson MD
Common to These Models
• Patient eligibility defined by diagnosis of
dementia and participation of a family caregiver
• Addition of psychosocial management options
• Care partnership with the family
• Specified communication pathways
• Tools for measuring outcomes
• Relatively small effect sizes
Finding High-Needs Patients and
Caregivers
• Goal: predict service needs and gaps by data
easily acquired in primary care
• Community sample of 215 patient/caregiver pairs
– Dementia-related services needed/used in past year, 8
physician-initiated and 8 psychosocial case managerinitiated. Scored as # needs and # gaps.
– Caregiver stress (1 item, scored 1-5) and # of patient
behavior problems (5 items, scored 0-5)
• Result: stress and behavior problems by far the
strongest predictors of service needs and gaps
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Services: Physician Management
2
1.8
1.6
Low behavior
problems
# of Needs
1.4
1.2
1
0.8
0.6
0.4
0.2
0
High behavior
problems
1
2
Low Stress
Medium Stress
3
1.2
# of Gaps
0.9
0.6
0.3
0
High Stress
© 3-11 Soo Borson MD
Services: Psychosocial Care Management
4.5
4
3.5
Low behavior
problems
# of Needs
3
2.5
2
1.5
1
0.5
0
High behavior
problems
1
2
3
Low Stress
Medium Stress
High Stress
2.2
2
1.8
1.6
# of Gaps
1.4
1.2
1
0.8
0.6
0.4
0.2
0
© 3-11 Soo Borson MD
Screen:
Caregiver Stress +
Patient Behavior
High stress +
>1 behavior
problems
Low to moderate
stress + >1 behavior
problems
Low to
moderate
stress + 0-1
behavior
problems
Urgent,
intensive
physician/case
manager
collaboration
May need
geropsychiatrist
Primary Care
Refer to case
manager
Primary Care
Encourage
reporting of
new problems
© 3-11 Soo Borson MD
Physician-Based Medical Home
(Lessig et al)
Design
• Clinical quality
improvement pilot
• 21 initial patient/family
dyads (now 50)
• Shared medical visits
• 3 initial groups: early onset,
late onset, and medically
complex
Setting
Dementia specialty
clinic
Experience
• ↓ unnecessary
hospitalizations and
clinic visits
• ↑ Pt & Cg support and
problem solving
• Satisfaction with care
• More efficient use of
physician and social
work time
• More timely acceptance
of shared care
© 3-11 Soo Borson MD
Improving Care:
Moving Into the Medical Home Neighborhood
• Patient Centered Medical Home
– Central hub for information, primary care, and care
coordination for a defined group of patients
• Each patient has a personal physician who directs a team
• Collective responsibility for the patient’s health care
• Patient Centered Medical Neighbor
– Specialty/subspecialty practice committed to
collaboration with a PCMH
• Standards for linking with a PCMH
• For some patients, PCMN physician may provide the PCMH
Laine, Sinsky, Lee: Ann Intern Med 2011
© 3-11 Soo Borson MD
Thanks to…
Mary Lessig BS
Jim Scanlan PhD
Shaune DeMers MD
Peter Vitaliano PhD
Jeff Hummel MD, MPH
Kathy Gibbs RN, CNS
Teresa Holder MSW
Beth Zuhr BA
and our residents and fellows whose training turned the practice
into words
© 3-11 Soo Borson MD