The UCSF and UNMC Dementia Care Ecosystem: Using Innovative Technologies to Personalize and Deliver Coordinated Dementia Care

We propose a proactive, continuous, and personalized dementia care model that is a paradigm shift from current reactive, intermittent and generic approaches. Dementia patients and caregivers at the highest risk for costly and burdensome health outcomes will have resources offered to them for care planning, management, and functional assessment. Care Ecosystem is an innovative comprehensive and proactive dementia care program. With Care Ecosystem the primary point of contact for patients and families will be a Care Team Navigator (CTN) who will carefully monitor patient and caregiver needs and provide links to targeted education, community resources, and health care professionals as needed. An innovative “dashboard” will guide efficient and personalized communication between the care team, and the patient and family. Care Ecosystem has four primary modules. (1) A Caregiver Module will offer on-line educational forums and will connect families with community resources. (2) A Decision-Making Module will use the patient and family’s values to facilitate proactive medical, financial, and safety decisions. (3) A Medication Module will track and reduce inappropriate medications or doses, and trigger a pharmacist review when indicated. (4) A Functional Monitoring module will use smartphones and in-home sensors to rapidly detect and respond to changes in functional status. The financial model we have selected is a sliding scale monthly enrollment fee with a bi-annual pay for performance (P4P) component. Care providers receive bonus payments from Medicare based on performance on quality, access, patient/caregiver experience and efficiency goals. Also, we will determine our caregivers’ willingness-to-pay for this service, and will explore a sliding scale monthly enrollment fee payment as a method of sustaining this care model.