Adaptation of the Care Ecosystem Intervention for Individuals with Dementia in a High-Risk, Care Management Program

The Care Ecosystem (CareEco) model is a telephone-based dementia care program providing standardized, personalized and scalable support and education for caregivers and persons living with dementia (PLWD), medication guidance, and promotion of proactive decision-making. It has demonstrated improvement in quality of life for PLWD and reduced unnecessary healthcare expenditures. We initiated a pragmatic, embedded randomized pilot trial of an adapted CareEco model for nurses who provide high-risk care management and are embedded in primary care practices within a large healthcare system. Outcomes include feasibility of collecting emergency department visits, usability and acceptability of the intervention by nurse care managers, caregiver strain, behavioral symptoms of dementia and healthcare expenditures. Challenges of implementation include engaging key care management leaders, adaptation of the CareEco training modules for nurses, identification of primary caregivers, training and reinforcing knowledge and skills of the nurses, embedding clinical assessments into care manager workflows and integration with the EMR.

Predictors of Care Management Utilization

Care management is the process of planning and coordinating care to assist individuals or families in managing their health. This may involve managing inpatient or outpatient medical care or helping with other household, legal, or financial needs. Care management service providers are challenged in knowing how best to allocate limited resources (i.e. care manager time) to best meet client needs. Research shows predictors for increased care management needs include advanced age, multiple comorbidities, frequent care transitions, and private insurance coverage, but the association of objectively measured functional assessments and care management hour utilization is unknown. This secondary data analysis aimed to identify factors that predict the amount of care management service among low-income older adults enrolled in a care management program. We used de-identified care management data from the electronic health record at 1 social service agency. We used multivariate regression to predict the number of hours of care management utilization from demographics, comorbidities, intake ADLs/IADLs, physical health, and self-reported quality of life. We found moderate to strong correlations between physical health and quality of life (r=0.58) and activities of daily living and instrumental activities of daily living (r=0.81). Baseline self-reported quality of life predicted the number of hours of care management utilization (p=.03; beta = 6.75). Quality of life can be useful in predicting the number of service hours that a particular client may require from a care management program and should be considered as an intake question to assist social service providers in allocating hours adequately to clients.

Exploration of Fatalism and Religiosity by Gender and Varying Levels of Engagement Among Mexican-American Adults of a Type 2 Diabetes Management Program

Objectives: Purpose of study is to explore the roles religiosity and fatalistic beliefs play in diabetes management among newly, currently, and long-term enrolled Mexican-American participants in a Type 2 diabetes mellitus (T2DM) chronic care management program.Methods: In 2017, study participants (n = 15) completed a semi-structured interview in their preferred language (English or Spanish). Sample was stratified by amount of time individual had been enrolled as a participant of the Salud y Vida program: newly, currently, or long-term. Interviews assessed religious beliefs, beliefs concerning the cause(s) of diabetes, perceived relationship between religiosity and fatalistic beliefs with T2DM management, and the appropriateness of discussing such topics with a health professional. Interview responses were analyzed using ATLAS.ti 8.Results: Themes identified included: perceived autonomy over diabetes prognosis, motivators for self-care, discussions of personal beliefs in the healthcare setting, and the church's role in diabetes management.Conclusions: Among this sample, religiosity and religious fatalism played a complex role in coping with and managing diabetes. Long-term enrolled and male participants expressed beliefs of divine control over health, and a connection between religiosity and health behavior. Long-term enrolled participants felt religious and fatalistic beliefs may be suitable and beneficial to discuss in the healthcare setting.

Evidence for a Novel Care Management Program for Low-Income Older Adults

The purpose of this study was to evaluate the implementation and effectiveness of a novel care management program for low income older adults in Chicago. Older adults (n=200) who had annual income below $31,225 but about the state level for home and community based services were received care management. Program participants completed a battery of assessments (UCLA Loneliness Scale, single item Quality of Life and Physical Health scales, and Nutritional assessment) at initial assessment and 1-year follow-up. We also conducted interviews with clients and care managers. We used a t-test to evaluate participant outcomes and coded qualitative data to identify themes. Results showed no significant differences between baseline and 1 year follow-up indicating that this care management program kept participants stable. Only 5 of 200 (2.5%) of clients transitioned to a nursing home. This study contributes important results on a novel program to sustain vulnerable older adults in the community.

Transitional Care Management: Evidence for Novel Implementation Models and Rehabilitation Implications

The transition between healthcare settings is a complex process presenting challenges for effective and consistent communication between older adults, their caregivers, and healthcare providers. These challenges often result in adverse health events and re-hospitalizations. Further, once transitioned to home, older adults often need ongoing care management and support and evidence for models remains unclear as to the precise parameters of supports needed for comprehensive care. This symposium will provide an overview of the evidence for both interdisciplinary care management models and transitional care programs, present the implementation of a care management program for low income older adults at one social service agency, and provide evidence-based tools for older adult functional assessment and decision-making for transitional care. The speakers will present new tools from the American Physical Therapy Association home health toolbox that promote patient-centered health care decision-making to facilitate successful transitions that reduce resource use and hospital readmission. The speakers will also discuss the implementation of a care management program for older adults in a care gap (having too much income for Medicaid home and community-based services, but still <200% of the federal poverty line). An implementation framework for the needs assessment will be highlighted and 1-year program outcomes will be presented. Attendees will learn strategies for interprofessional collaboration, enhanced communication, and advocacy within the interprofessional team to facilitate improved care management and transitional services for older adults.

Implementation of a Care Management Program for Low-Income Older Adults

The focus of this session will be on the implementation of a new care management program in Chicago for low income older adults. Framed by the Exploration, Installation, Initial Implementation, and Full Implementation framework, the presenter will first discuss the process and outcomes of a needs assessment which informed the program. The presenter will share strategies and lessons learned from getting the program off the ground and initial lessons learned which informed the full program as it is operated today. In 2 years, the program has grown from 1 FTE to 4.5 FTE and to 250 clients. The presenter will provide strategies for managing growth while maintaining quality care. Finally, the presenter will provide information on the program's collaboration with a researcher to enhance evidence-based service delivery within the care management program. Participants will learn specific strategies they can take back to their own communities to implement care management programs.