Coordinating Care for Older Adults with Alzheimer’s
Recently, Hall of Famer and longtime Tennessee women’s basketball coach Pat Summitt lost her battle with Alzheimer’s disease. She was 64 years old. Alzheimer's is perhaps the most common form of dementia, and a major chronic condition faced by many older adults. In fact, nearly 95% of Medicare beneficiaries with dementia have at least one other chronic health condition. Alzheimer’s disease being the most prominent. Alzheimer’s disease usually occurs in individuals who are 60 years old and older. Starting at age 65, the risk of developing the disease doubles every five years. By age 85 years and older, between 25% and 50% of people will exhibit signs of Alzheimer’s disease.
Alzheimer’s disease is a potentially debilitating disease that requires coordinated care that addresses the medical, behavioral, and social care needs of the patient. Memory loss is the first symptom in the early stages. Followed by impaired judgment, and decreased reasoning which exacerbates functional decline and one’s ability to manage their own care. Hospital, home health, and skilled nursing facility costs and acute health episodes are higher for beneficiaries with Alzheimer’s.
The impact on practices and health systems, particularly those under risk-adjusted arrangements, can also be significant. Many of the chronic conditions for older adults with Alzheimer’s fall under capitated and risk-based outcomes benchmarks and compensation. Most of these patients are unable to balance both Alzheimer’s associated dementia and complex chronic conditions. As self-management is key for older adults with chronic conditions, being able to remember medications, therapies, dietary instruction and preventive care activities diminishes over time in patients with Alzheimer's disease. CCM and TCM Alzheimer’s care management plan can help providers and family members with:
- management of transitions between practice settings and providers
- medication management, review, and oversight,
- Alzheimer’s education, counseling, and ongoing consultation
- decision-making, including hospice and palliative care.
Chronic care (CCM) and transitional care managers (TCM) work with primary care physicians to develop and implement an Alzheimer’s care plan. Such a plan can help address concerns of wandering, falls, forgetfulness and self-harm. Multifaceted Alzheimer’s care coordinates efforts across healthcare providers, social service agencies, and community organizations. Older adults with Alzheimer’s and complex chronic conditions can benefit from focused care management, routine check-ins, monthly calls, and care planning. Partnering with care management like NavCare can lower risks associated with Alzheimer's disease, reduce acute care costs, provide family support, and produce better health outcomes.
About the Author
Joseph F. West, ScD, is a population health and data analytics leader with over 10 years of research and enterprise consulting experience. He is a recognized leader in the development of outcomes-based healthcare. Joseph has served as Chief Population Health Officer, Senior Epidemiologist, Program Director, and Adjunct Assistant Professor. As a consultant and content creator, his current work focuses on population health management (PHM), health information technology (HIT), care coordination innovation, and healthcare risk management.