The Aging Brain Care Medical Home: Preliminary Data.

The Aging Brain Care (ABC) Medical Home aims to improve the care, health outcomes, and medical costs of Medicare beneficiaries with dementia or depression across central Indiana. This population health management program, funded by the Centers for Medicare and Medicaid Services Innovation Center, expanded an existing collaborative dementia and depression care program to serve 1,650 older adults in a local safety-net hospital system. During the first year, 20 full-time clinical staff were hired, trained, and deployed to deliver a collaborative care intervention. In the first 18 months, an average of 13 visits was provided per person. Thirty percent of the sample had a diagnosis of dementia, and 77% had a diagnosis of depression. Sixty-six percent of participants with high depression scores (Patient Health Questionnaire-9 score ≥14) had at least a 50% reduction in their depressive symptoms. Fifty-one percent of caregivers of individuals with dementia had at least a 50% reduction in caregiver stress symptoms (measured by the Healthy Aging Brain Care Monitor-Caregiver Version). After 18 months, the ABC Medical Home has demonstrated progress toward improving the health of older adults with dementia and depression. Scalable and practical models like this show initial promise for answering the challenges posed by the nation's rapidly aging population.

Development and Implementation of an Electronic Decision Support to Manage the Health of a High-Risk Population: The enhanced Electronic Medical Record Aging Brain Care Software (eMR-ABC).

INTRODUCTION: Health care systems in the United States are transitioning from volume-based purchasing models to value-based purchasing models that demand both delivery of personalized care for each patient and cost-effective population health management. The enhanced medical record for aging brain care (eMR-ABC) software is an electronic decision support system that facilitates the management of a high-risk population suffering from aging brain disorders such as dementia. METHODS: Using the lenses of the Complex Adaptive System and the Reflective Adaptive Process, we assembled an interdisciplinary team of clinicians, health services researchers, and software developers who designed, implemented, evaluated, and continuously modified the eMR-ABC to meet the needs of care coordinators who manage the health of a targeted high-risk population. RESULTS: The eMR-ABC captures and monitors the cognitive, functional, behavioral, and psychological symptoms of a registry of patients suffering from dementia or depression as well as the burden of patients' family caregivers. It provides decision support to care coordinators to create a personalized care plan that includes evidence-based nonpharmacological protocols, self-management handouts, and alerts of medications with potentially adverse cognitive effects. The software's built-in engine tracks patient visits and on-demand functionality to generate population reports for specified indicators. DISCUSSION: Population health programs depend on data collection and information systems with the ability to provide valuable and timely feedback on an ongoing basis. Following these guidelines, the eMR-ABC was designed specifically to meet the management needs of a high-risk population.