Summary

Informed by decades of dementia care clinical expertise, best practice recommendations, and clinical studies, MIND at Home is an effective, comprehensive, home‐based dementia care coordination model that systematically assesses and addresses a broad range of dementia‐related care needs that place elders at risk for health disparities, hospitalizations, unwanted long term care placement, poor quality of life and family caregivers at risk for burnout and health impacts. Yet translation into practice has been slow primarily due lack of data on its potential for return on investment and its value proposition to health systems, health plans, and providers, as well lack of data on how to effectively refine the model to integrate into existing health care delivery environments. This grant supports a partnership with University of Maryland Baltimore County, Jade Gong & Associates LLC, and Johns Hopkins Home Care Group, with the support of Maryland Primary Care Program, Maryland Medicaid, and Johns Hopkins Alliance for Patients to strategically advance the dissemination and translation of John Hopkins University’s evidence‐based MIND at Home model, in the context of Maryland’s new primary care program (MDPCP) as a transformative tool to achieve greater care coordination and value for a vulnerable cognitively impaired population.

Project Details

This two‐year collaborative grant seeks to advance the dissemination and translation of The John Hopkins University’s evidence‐based dementia care coordination model, Maximizing Independence at Home (MIND at Home), into practice so that the program is as widely available and accessible to persons living with dementia and their care partners as possible. First, leveraging participant data from prior federally-funded research studies on the MIND at Home program, we will conduct a cost savings analysis using Medicare and Medicaid data to better understand whether the program has a financial impact on health care spending and how the program may change patterns of health care use (such as decreasing hospitalizations or nursing home admissions). Our hypothesis is that the MIND at Home program reduces health care spending, and if so, this cost evaluation will help establish a strong value proposition to support the adoption of the program into practice by payers and providers. Next, we will engage with primary care providers, provider‐based organizations, and health plans participating in Maryland's new Primary Care Program to understand provider needs related to caring for Medicare beneficiaries with dementia, the perceived value of MIND at Home, and to gauge interest in potential pilot partnerships. Finally, using data and results from the first two aims, we will then refine the MIND at Home program delivery process and materials for successful integration into Maryland's Primary Care Program and development a viable payment model that will support long term sustainability of program financing. The research is innovative in that it (1) advances dissemination of a novel, home-based dementia care coordination model (MIND at Home) , (2) leverages and extends data from previous federally‐funded research studies to estimate net cost savings and develop a robust value proposition to a range of perspective payers; (3) leverages the start‐up of the new Maryland Primary Care Program (MDPCP) to support the rapid transformation of dementia care delivery and achievement of value‐based care in Maryland, with the longer term goal of generalizing learnings nationally within the similar CMS Primary Care First Pay Model alternative payment model; and (4) has the potential to reduce health disparities and reach some of the most vulnerable and underserved populations through the MDPCP. Even though new evidence-based approaches that optimize Alzheimer’s disease and dementia care and reduce suffering are available now, programs have slow to disseminate to practice. If successful, results of this research could accelerate dissemination of the evidence-based MIND at Home dementia care coordination program into the MDPCP and similar models (CMS Primary Care Pay Model) making home-based care coordination services such as these more widely available and accessible.