Piloting the MIND at Home Dementia Care Navigation Program in primary care

Area of Science:

• Gerontology
• Primary Care Medicine
• Dementia Care

Background:

• Persons living with dementia (PLWDs) often experience fragmented care and unmet needs, despite primary care's crucial role.
• Existing dementia care models struggle to adequately address the complex needs of PLWDs and their care partners within primary care settings.
• The MIND at Home Dementia Care Navigation Program offers a potential solution by integrating home-based assessments and care navigation into primary care.

Purpose of the Study:

• To evaluate the feasibility and potential impact of adapting and implementing the MIND at Home program into primary care.
• To assess the program's ability to identify and address dementia-related care needs in PLWDs and their care partners.
• To determine the program's effect on healthcare utilization outcomes within two large US health systems.

Main Methods:

• A pilot pragmatic clinical trial design was employed to integrate the MIND at Home program into primary care.
• Process measures included comprehensive needs assessments, personalized care plan development, and care navigation for 105 PLWD-care partner dyads over 3 months.
• Feasibility of collecting clinic-based outcomes, such as hospital transfers and medication data, was assessed using electronic health records and validation data.

Main Results:

• The MIND at Home program was successfully implemented with fidelity in two primary care health systems.
• All participating dyads received needs assessments and personalized care plans, with 74% of identified needs being addressed.
• Health care utilization measures were feasible to collect, and trends suggested a potential reduction in hospital transfers, particularly for those with advanced dementia.

Conclusions:

• The MIND at Home program's integration into primary care is feasible and effective in addressing the needs of PLWDs and their care partners.
• This evidence-based approach, combining clinic and home-based services, has the potential to reduce unmet care needs and hospitalizations.
• Further investigation into the observed trends in hospital transfers is warranted, especially for individuals with more advanced dementia.