The article Partners in Dementia Care; A Care Coordination Intervention for Individuals with Dementia and Their Family Caregiver, by Judge, Bass, Snow et. al (2011) describes a care coordination intervention called Partners in Dementia (PDC) that is for veterans with dementia and their caregivers.

The intervention involved a formal partnership between VA medical centers and local Alzheimer’s Association chapters (in Houston and Boston).

• Two care coordinators (one from the VA and one from the Alzheimer’s Association) provided telephone based support to patients and their caregivers over a 12 month period.
• The program addressed medical and non-medical needs.
• It also provided an upfront multidimensional assessment of both the patient and the caregiver, development of goals and action steps, and ongoing monitoring by both care coordinators.

 Patients were eligible if they were recently diagnosed with Alzheimer’s in the last 2 years.

Here's how it worked:

• Two care coordinators (one from each organization) would be assigned to one veteran patient with dementia and his or her caregiver.
• The care coordinator from the VA focused more on the medical and non-medical needs of the patient and helped them effectively use VA resources, while the care coordinators from the local chapter of the Alzheimer’s Association focused more on the needs of the informal caregivers.
• The care coordinators would call the patient and caregiver twice a month for the first 3 months and then monthly thereafter for the duration of the 12 months.
• The care coordinators would work together with the patient and caregiver to create specific goals related to disease education, emotional support, and links to medical and nonmedical resources.
• Action steps were also included to help them reach their goals like accessing benefits or services offered by the VA or determining local day care offerings.
• An electronic medical record was used to help ongoing monitoring and communication between care coordinators.
• The program helped to improve psychosocial issues of patients and caregivers, reduced hospital admissions, and improved access to VA outpatient services.

Clinical application:
 Through partnerships between two organizations, like the VA and Alz. Assn, and with case coordinators working together providing ongoing monitoring, coordinated care with the patients and caregivers has many benefits.

It may help decrease fragmented services, help to cover a wide array of issues, acknowledges the importance of the caregiver role and needs, and features a consumer-directed philosophy.

The patients and caregivers were empowered and taking action in their own support and needs; and this also allowed for more cost-efficient care.

Hopefully this can be implemented in other settings to really help facilitate the care of patients and their caregivers; to help meet their needs, reduce caregiver strain and help patients utilize resources available to them.  Although this intervention was only 12 months long, this could continue further if needed too.

Judge, K.S., Bass, D.M., Snow, A.L., et al. (2011) Partners in dementia care: a care coordination intervention for individuals with dementia and their family caregivers. Gerontologist, 51(2), 261-72. doi: 10.1093/geront/gnq097

http://www.innovations.ahrq.gov/content.aspx?id=3345