2. GOING FURTHER TOGETHER: INTERDISCIPLINARY, COLLABORATIVE UNIVERSITY OF SOUTH CAROLINA BRAIN HEALTH NETWORK TO EMPOWER PATIENT-CENTERED APPROACHES TO INNOVATIVE DEMENTIA CARE

Abstract

Introduction

Approximately 6.9 million older Americans are living ith Alzheimer’s dementia (AD) and other dementias, ith prevalence increasing with age, affecting 5.0% of people ages 65-74 years, 13.2% of people ages 75-84 years, and 33.4% of people above age 85. While the diagnosis of Mild Cognitive Impairment (MCI) or dementia can facilitate access to treatment and interventions, delays in timely diagnosis, as well as coordination of care across caregivers and community resources serve as barriers, especially in primary care settings, where the majority of older adults receive their medical care. Such barriers include volume of primary care provider (PCP) visits with brief durations for each, lack of sufficient access to collateral informants, and variable confidence and expertise of PCPs to screen, diagnose and subsequently manage patients with cognitive disorders. With the advent of biomarkers for detection, disease-modifying therapies for the treatment of MCI and AD, and the growing focus on prevention and health promotion in midlife, responding to innovative approaches in diagnostics and therapeutics is a critical yet imminent challenge for PCPs and dementia specialists.

In response to these challenges and needs, the University of South Carolina (USC) Brain Health Network (BHN) was developed as a permanent, State-funded initiative with the main mission of ensuring statewide access to advanced, collaborative cognitive care, and to provide community support throughout South Carolina. Responding to needs assessment and focus groups of caregivers statewide, the BHN represents a collaborative, interdisciplinary partnership with health system providers (Primary Care, Geriatric Psychiatry, Neurology, etc.) to set up a seamless and integrated process to support front-line providers (PCPs) and aim to ensure persons with Alzheimer’s Disease and Related Dementias (ADRD) and their caregivers receive support and obtain a clear understanding of their health care system and care navigation in their community.

This poster describes the development and operational processes of the BHN, highlighting the interdisciplinary aspects of dementia care, as well as the interprofessional role of community health workers (CHW), through relationships with organizations and formal partnerships with the Alzheimer's Association and the Area Agency on Aging/Council of Government, including Area Agency on Aging departments statewide, to facilitate patient engagement and caregiver support state-wide to promote health and enhance care navigation across the continuum of dementia care.

Methods

The BHN partners with health systems to achieve 3 main goals: (1) provide greater access and coordinated care for patients and caregivers, (2) provide further support and education for individuals diagnosed (and their caregivers), and (3) provide access to innovations in treatment and diagnostics, especially in under-served areas. An algorithm (See Figure 1) for clinical evaluation and care coordination was developed, which includes:

(1) Advanced Cognitive Screening – performed by a Speech Language Pathologist (SLP) or Masters level social worker with specialized cognitive training:

- 90-minute detailed cognitive testing in the patient’s PCP office to detect mild or subtle cognitive issues.

- Clinical documentation in the patient’s electronic health record (EHR) and accessible to both the PCP and specialty providers.

(2) Community Engagement and Navigation – performed by a certified Community Health Worker (CHW) (Figure 2)

- CHW located in the community and has specialized training in ADRD patient support.

- CHW connects with the patient/caregiver in the patient’s PCP office and then works with the patient/caregiver continuously to provide navigation, connections to local/community resources.

- Performs Community Health Integration (CHI) activities that meet CMS standards.

- CHW patient/caregiver encounters are documented in the EHR and accessible to the patient’s PCP and specialty providers.

(3) Enhanced Specialty Provider Access – performed by BHN Advance Practice Provider.

- Partnership with health systems to create additional access to Geriatric Psychiatrist and Neurologist for USC BHN patients.

Results

The following Key Performance Indicators (KPI) have been developed and will be tracked to evaluate and maintain fidelity to the goals noted above, informed by community needs and caregiver concerns.

- Cognitive Screening Wait Time – Baseline 6-9 Months.

• Goal: Reduce to ≤1 Month

- Cognitive Assessment Wait Time – Baseline 6-9 Months.

• Goal: Reduce to ≤1 Month

- Cognitive Assessment No Show Rate - Baseline ∼50%.

• Goal: Reduce to ≤ 30% for clinical sites

- Patient Treatment Compliance – Baseline 56%.

• Goal: Reduce to ≤75% for clinical sites.

- PCP Confidence–Managing ADRD - Baseline will be established and tracked quarterly starting 2025.

- Caregiver Burden – Baseline will be established and tracked quarterly with the expectation that perceived burden will be significantly reduced.

- BHN Patients Screened – tracking monthly volume.

- BHN Community Referrals – tracking monthly volume.

Conclusions

The unique, collaborative, and interdisciplinary service model created by USC Brain Health promotes significant dementia care engagement at the individual and community levels, by leveraging the convenience of local care and trust of community PCPs. This will allow for grass-roots engagement and create a directed population health focus through lifestyle and treatment interventions, but also critical relationships built with patients and caregivers through follow-up that allow for shared decision-making and a greater degree of shared engagement with cognitive care plans. Ongoing appraisal will assist with translating research into compelling guidelines and call to action at the community level.