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11/8: Care Ecosystem Provides Personalized Help for Caregivers and Patients

November 8, 2015

Most patients with dementia receive care and support from spouses, children, or other caregivers, but caregiving for a patient with memory or behavior problems is incredibly challenging. Some caregivers feel reluctant to ask for help, some do not know what they need or where to look, and sometimes there is just not much help available.

To help manage and prepare for the challenges of dementia care, the University of California, San Francisco (UCSF) Memory and Aging Center and the University of Nebraska Medical Center (UNMC) have developed a proactive care program called Care Ecosystem. The Care Ecosystem (CE) offers personalized care to patients and their caregivers. Each patient and caregiver pair connects with a Care Team Navigator (CTN) who regularly calls them, and offers education, guidance and customized links to community resources. The CTN works with a clinical team—a nurse, social worker, and pharmacist—to help deliver the best possible care to families coping with different stages of illness.

The CE is also using new technologies to help the CTN and clinical team keep track of patient and caregiver needs. Smart watches and in-home sensors help the team measure changes in behaviors like sleep and walking, and are designed to help the CE deliver excellent, consistently available care that is also more affordable. 
A coordinated and supportive care model like CE could be groundbreaking for the growing number of people affected by dementia. Our hope is to show that a telephone-based program—which would be easily accessible in both urban and rural areas—improves quality of life while reducing the overall cost of care. We are seeking participants who have a diagnosis of dementia and a caregiver who supports them to help us test this model over the next two years. For every three patients enrolled, two will receive the CE intervention and one will be surveyed about regular care they are receiving. A Health Care Innovation Award from the Centers for Medicare and Medicaid Services is sponsoring the Care Ecosystem study.

To join the study, patients must:

  • Be 45 or older
  • Have a dementia diagnosis
  • Be covered by Medicare/Medicaid
  • Live in California, Nebraska, or Iowa
  • Have a caregiver or someone who helps them

For more information, contact (415) 514-8707 or CareEcosystem.org.

The Care Ecosystem study is supported by Grant Number 1C1CMS331346 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services to help improve dementia care for patients and their caregivers. The content of the present blog post is solely the responsibility of the authors and does not necessarily represent the official views of the U.S. Department of Health and Human Services of any of its agencies.

—Kate Possin, Ph.D. and Anna Milter




View all 30 Days of Caregiving blogs (to date) at caregiver.org/blog.