Improving How People Living With Dementia Are Selected for Care Coordination

This project will use a pragmatic clinical trial embedded in an accountable care organization (ACO) to determine the comparative effectiveness of two different approaches for selecting PLWD to receive support from care coordinators: (1) an approach that assigns PLWD to care coordinators based on care partners' self-reported difficulty with care coordination, or (2) usual care, which generally assigns PLWD to care coordinators after hospital discharge, regardless of perceived need. The investigators will include community-dwelling Medicare beneficiaries ≥65 years old with dementia who have been attributed to the NewYork Quality Care ACO and who have fragmented care. The investigators will randomize the participants into two groups. This study is highly pragmatic, and the intervention is sustainable and scalable. Moreover, the proposed approach has the potential to improve care delivery and outcomes for PLWD.

Inclusion criteria

• Medicare beneficiaries ≥65 years old who:
• Are attributed to the NewYork Quality Care accountable care organization by Medicare,
• Have dementia (as measured in claims using the Bynum standard 1-year definition),
• Reside in the community, and
• Had fragmented ambulatory care in the previous 12 months (defined as a reversed Bice-Boxerman Index greater than or equal to the median score for this population, using Medicare claims)

Exclusion criteria

• Those who reside in long-term care or nursing home facilities (based on addresses in Medicare claims), or
• Enrolled in home hospice