Eskenazi Health earned a 2014 Gage Award honorable mention in the population health category.

Using a mobile office approach that respects patient comfort and a cost-efficient staffing solution to expand capacity, Eskenazi Health has significantly reduced depressive, behavioral, and psychological systems of older adults suffering from dementia or depression.

Eskenazi Health, in Indianapolis, partnered with scientists at the Indiana University Center for Aging Research to establish its Aging Brain Care (ABC) Medical Home in 2009. The program reflects growing concern about a U.S. population of dementia patients expected to reach 16 million by 2050 and $30 billion in annual Medicare spending for dementia and depression care.

The ABC medical home was designed to help primary care clinicians deliver best practices in the management of community-dwelling older adults suffering from dementia or depression. Much of the intervention is targeted to co-manage or support primary care physicians and provide personalized care to improve patients’ and caregivers’ self-management skills and coping behavior.

Since 2012, with the support of a federal Innovation Award, the program has expanded to provide care to more than 1,500 patients in the system of community health centers affiliated with Eskenazi.

Using a new care model

The program’s mobile office concept allows clinical staff to take the physical, emotional, and psychological comfort of patients and caregivers into account when scheduling appointments. Mobile office sites may include the patient’s home, a primary care or specialty clinic, the hospital or emergency department, or other community setting. ABC staff promote care coordination by serving as liaisons between the patients and caregivers, primary care physicians, specialty care providers, and community resources.

Developing a new workforce

The recruitment, selection, and training of a new type of care worker – the care coordinator assistant (CCA) – has been a crucial component of the program’s expansion, says Catherine A. Alder, JD, MSW, chief administrator of the ABC program.

The CCA serves as liaison between the patient and family caregiver and the hospital-based care team, all under the close supervision of a registered nurse and social worker care coordinators. The position was specifically modeled after studies and recommendations for increasing the size of a population served by shifting tasks that require less training and expertise to less expensive members of the care team.

Seeing results

In its first year, the ABC program hired, trained, and deployed 20 full-time clinical staff, who provided 3,433 home visits to more than 1,500 patients enrolled in the program. After one year, the program saw these impressive results:

  • Sixty percent of patients with high depression scores had at least a 50 percent reduction in their depressive symptoms.
  • Forty-seven percent of patients had at least a 50 percent reduction in their behavioral and psychological symptoms of dementia.
  • Fifty-six percent of caregivers of patients with dementia had at least a 50 percent reduction in caregiver stress symptoms.

For more information on Eskenazi Health’s Aging Brain Care Medical Home, contact:

Catherine A. Alder, JD, MSW
Chief Administrator, Aging Brain Care
Eskenazi Health
317.880.4800
catherine.alder@eskenazihealth.edu