Care EcoSystem: Ochsner Health System

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

COMPLETED

Total Enrollment

290 participants

Study Classification

OBSERVATIONAL

Study Start Date

2019-02-26

Study Completion Date

2022-05-01

Brief Summary

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1. To determine the feasibility and acceptability of the Care Ecosystem program in the Ochsner clinical setting.
2. To assess the effect of the Care Ecosystem program on health care cost and quality care quality as measured by primary outcome variables.

* Adapted from the Care Ecosystem, memory.ucsf.edu/Care-Ecosystem

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Detailed Description

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Conditions

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Dementia

Study Design

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Observational Model Type

COHORT

Study Time Perspective

PROSPECTIVE

Study Groups

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Dementia

The target population includes patients seen at Ochsner Clinic Foundation, \>=55 years old, diagnosed with dementia, and meeting other inclusion/exclusion criteria. this study will recruit subjects identified as high utilizers of the Ochsner System. This will be defined by \>= 2 ED visits, \>= 2 Hospitalizations, or some combination prior to baseline. We will co-variate by insurance plan.

Care EcoSystem

Intervention Type BEHAVIORAL

This is a care management program and health care outcomes feasibility study utilizing the dementia Care Ecosystem (CE) program developed at UCSF and tailored to high need Ochsner PWD (patient with dementia) and their CGs (caregivers). Dyads (CGs and PWD) will receive a tailored clinical assessment addressing dementia severity, PWD and CG needs, education/strategies to management common dementia issues, medical issues and medication reconciliation, caregiver wellness strategies, linkages to community-based resources, advance care planning, education about the risk of ED and hospitalization, and care coordination with other specialties. Dyads will be followed on a monthly basis to monitor needs, provide support, and problem solve issues.

Interventions

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Care EcoSystem

This is a care management program and health care outcomes feasibility study utilizing the dementia Care Ecosystem (CE) program developed at UCSF and tailored to high need Ochsner PWD (patient with dementia) and their CGs (caregivers). Dyads (CGs and PWD) will receive a tailored clinical assessment addressing dementia severity, PWD and CG needs, education/strategies to management common dementia issues, medical issues and medication reconciliation, caregiver wellness strategies, linkages to community-based resources, advance care planning, education about the risk of ED and hospitalization, and care coordination with other specialties. Dyads will be followed on a monthly basis to monitor needs, provide support, and problem solve issues.

Intervention Type BEHAVIORAL

Eligibility Criteria

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Inclusion Criteria

* Male or female ≥55 years of age at baseline
* Probable dementia diagnosis as evidenced by one or more of the following criteria:

* Dementia listed on medical record problem list as of January 1, 2015 or later, or, in the opinion of the referring provider has dementia
* Prescribed with any of the following: donepezil, memantine, galantamine HBR, rivastigmine, or tartrate; or, in the opinion of the referring provider, could take such medication
* Lives in community

Exclusion Criteria

* Documented history of Multiple Sclerosis, ALS, Traumatic Brain Injury, Huntington's Disease, Schizophrenia, Bipolar Disorder, or current Substance Abuse Disorder
* Lives in a nursing home or assisted living facility
* Unable to complete monthly telehealth or phone visits

Minimum Eligible Age

55 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No