Implementing innovative models of dementia care: the healthy aging brain center
Open accessAbstract
BACKGROUND: Recent randomized controlled trials have demonstrated the effectiveness of the collaborative dementia care model targeting both the patients suffering from dementia and their informal caregivers. OBJECTIVE: To implement a sustainable collaborative dementia care program in a public health care system in Indianapolis. METHODS: We used the framework of Complex Adaptive System and the tool of the Reflective Adaptive Process to translate the results of the dementia care trial into the Healthy Aging Brain Center (HABC). RESULTS: Within its first year of operation, the HABC delivered 528 visits to serve 208 patients and 176 informal caregivers. The mean age of HABC patients was 73.8 (standard deviation, SD 9.5), 40% were African-Americans, 42% had less than high school education, 14% had normal cognitive status, 39% received a diagnosis of mild cognitive impairment, and 46% were diagnosed with dementia. Within 12 months of the initial HABC visit, 28% of patients had at least one visit to an emergency room (ER) and 14% were hospitalized with a mean length of stay of five days. The rate of a one-week ER revisit was 14% and the 30-day rehospitalization rate was 11%. Only 5% of HABC patients received an order for neuroleptics and only 16% had simultaneous orders for both definite anticholinergic and anti-dementia drugs. CONCLUSION: The tools of 'implementation science' can be utilized to translate a health care delivery model developed in the research laboratory to a practical, operational, health care delivery program.
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Four studies tested the impact of post-discharge interventions on patient or caregiver outcomes.
“Four studies tested the impact of post-discharge interventions on patient or caregiver outcomes. 20,21,23,24”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [24]
The Results and Evaluation Platform sections report patient outcomes, including emergency visits and 30-day readmissions, alongside a comparison with primary-care patients. But the intervention is described as dementia care with follow-up after an initial care-plan visit, not as a post-discharge intervention; the paper also says it did not evaluate the statistical significance of the comparison. This source cannot establish the citing sentence’s count of four studies. (LLM, conf=0.83)
Experimental — accuracy not yet measuredThe intervention components varied; one study tested only caregiver education while the remaining studies tested two or more components including caregiver education, discharge planning, follow-up visits, caregiver hotline, consultation with the geriatric team, counselling on caregiving skills, and medication review.
“The intervention components varied; one study tested only caregiver education 23 while the remaining studies tested two or more components including caregiver education, 20 discharge planning, 20,21,24 follow-up visits, 21,24 caregiver hotline, 21 consultation with the geriatric team, 20,21,24 counselling on caregiving skills, 24 and medication review. 24”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [24]
The Results section (‘The Operation of the Healthy Aging Brain Center’; page unavailable) describes follow-up visits, caregiver-skills counseling, team-based care, and physician review of medications. It does not describe discharge planning as an intervention component, and it describes implementation of a care model rather than a study testing those components. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThree studies evaluated post-discharge interventions which had a number of components including caregiver education, caregiver support, follow-up (face-to-face) visits, home visits, telephone call/email, caregiver hot-line, and medication review.
“Three studies evaluated postdischarge interventions which had a number of components including caregiver education, caregiver support, follow-up (face-to-face) visits, home visits, telephone call/email, caregiver hot-line, and medication review. 21,23,24”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [24]
The Results section, under “The Operation of the Healthy Aging Brain Center” (page unavailable), describes caregiver education and support, face-to-face follow-up, telephone contact, and medication management. It describes follow-up after an initial care-plan visit, not a postdischarge intervention, and does not establish home visits, email contact, or a formal medication review as components of this program. (LLM, conf=0.87)
Experimental — accuracy not yet measuredIn another study employing a multi-component post-discharge intervention, a reduction in the proportion of patients hospitalized within 30 days of discharge was reported.
“in another study, which employed a multi-component post-discharge intervention, reduction in the proportion of patients hospitalized within 30 days of discharge was reported. 24”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [24]
The Results section, “The Performance of the Healthy Aging Brain Center” (page unavailable), reports that 11% of hospitalized HABC patients were readmitted within 30 days, compared with 20% of primary-care patients. However, “The Operation of the Healthy Aging Brain Center” describes follow-up after an initial care-plan visit, not a post-discharge intervention; the comparison also does not establish that the intervention caused a reduction. (LLM, conf=0.87)
Experimental — accuracy not yet measuredOnly two studies tested a post-discharge intervention that had more than one component.
“Only two studies tested a post-discharge intervention that had more than one component. 21,24”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [24]
The Introduction (page unavailable) mentions two randomized trials of a collaborative dementia-care model, and the Results section describes an individualized care plan with eight components. Neither passage identifies those trials or the Healthy Aging Brain Center program as post-discharge interventions, so the post-discharge part of the claim is unsupported. (LLM, conf=0.78)
Experimental — accuracy not yet measured
The study that reported reduction in 30-day rehospitalization rates was the only study to include a medication review component that involved simplification of the patient's medical regimen and targeted medication appropriateness.
“This was the only study to include medication review component that involved simplification of the patient ' s medical regimen and targeted medication appropriateness.”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [24]
In Results, “The Operation of the Healthy Aging Brain Center,” the paper says the team aims to simplify patients’ medical regimens and that its physician reviews medications, focusing on the benefits and harms of anticholinergics. “The Performance of the Healthy Aging Brain Center” reports fewer 30-day readmissions than in the comparison group (11% versus 20%). The paper does not establish that this was the only study with such a medication-review component. (LLM, conf=0.85)
Experimental — accuracy not yet measuredDischarge interventions led to significant reduction in length of stay.
“discharge interventions had led to significant reduction in length of stay”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [24]
The Results section reports a shorter mean hospital stay for Healthy Aging Brain Center patients than for primary-care-clinic patients (5 versus 7 days). But the Evaluation Platform section says the differences were not evaluated for statistical significance, and the paper does not identify these services as discharge interventions. It therefore does not support the claimed significant reduction caused by discharge interventions. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThe postdischarge program (follow-up visits, telephone/email, medication review) delivered by a geriatric team resulted in lower use of high-risk medications (19% vs 40%) in patients living with dementia.
“The intervention resulted in lower use of high-risk medications (19% vs. 40%)”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [24]
The Results, ‘Performance of the Healthy Aging Brain Center’ (page unavailable), report that 19% of HABC patients versus 40% of primary-care-clinic patients had an order for an anticholinergic medication. The paper describes HABC follow-up and medication review, but not a postdischarge program; the comparison is observational and includes patients without dementia. It therefore does not establish that a postdischarge intervention caused lower use of high-risk medications among patients living with dementia. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThe same program resulted in reduction in 30-day re-hospitalization rates (11% vs 20%) in patients living with dementia.
“reduction in 30-day re-hospitalization rates (11% vs. 20%)”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [24]
The Results (The Performance of the Healthy Aging Brain Center) report 30-day readmission rates of 11% for hospitalized HABC patients versus 20% for PCC patients. The rates are for the HABC cohort, not specifically patients living with dementia; the Abstract reports that 46% of HABC patients had a dementia diagnosis. The comparison also does not establish that the program caused the difference. (LLM, conf=0.88)
Experimental — accuracy not yet measuredOf these two studies, only one reported reduction in 30-day rehospitalization rates.
“of these, only one reported reduction in 30-day rehospitalization rates 24”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [24]
The multidisciplinary team intervention involving collaboration with the primary care physician to discuss medications showed reduction in the proportion of patients re-hospitalized within 30 days of discharge.
“the multidisciplinary team intervention involving collaboration with the primary care physician to discuss medications showed reduction in the proportion of patients re-hospitalized within 30 days of discharge. 24”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [24]
Quality indicators for medication use were only reported by one study, which found lower use of high-risk medications.
“quality indicators for medication use were only reported by one study which found lower use of high-risk medications. 24”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [24]
Discharge interventions led to significant reduction in caregiver burden.
“discharge interventions had led to significant reduction in length of stay and caregiver burden . 23,24”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [24]
The Results describe monitoring caregiver stress and the Discussion describes an aim to reduce dementia-related burden, but neither reports a measured reduction in caregiver burden. Searches for discharge interventions and significant caregiver-burden outcomes found no passage establishing the claimed effect. (LLM, conf=0.76)
Experimental — accuracy not yet measuredMost included interventions targeted administration of medications by caregivers.
“most targeted administration of medications by caregivers”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [24]
The Introduction and Results describe a collaborative dementia-care model with caregiver support and some medication-related components. They do not report a set of included interventions, say that most targeted medication administration, or identify caregivers as administering medications. Searched for medication administration by caregivers and the interventions’ primary targets; no passage in our copy addresses that claim. (LLM, conf=0.76)
Experimental — accuracy not yet measuredTwo out of the five studies tested discharge interventions that involved communication with the primary care physician.
“Two out of the five studies tested discharge interventions that involved communication with the primary care physician. 22,24”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [24]
The Results section describes communication between the Healthy Aging Brain Center and primary care clinicians, but not discharge interventions. Searches for discharge interventions and five studies found no passage identifying two studies that tested communication with a primary care physician at discharge; page numbers were unavailable in our copy. (LLM, conf=0.74)
Experimental — accuracy not yet measuredIn quasi-experimental studies, hospital-based transitional care for people with dementia, compared to usual care, was associated with fewer hospital readmissions and decreased caregiver burden.
“In quasi-experimental studies, hospital-based transitional care for PWD, compared to usual care, was associated with fewer hospital readmissions and decreased caregiver burden.17–19”
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An Alternative Payment Model To Support Widespread Use Of Collaborative Dementia Care Models
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Coordinated Care Management For Dementia In A Large Academic Health System
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Ongoing Medical Management to Maximize Health and Well-being for Persons Living With Dementia
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Strengthening the Dementia Care Triad
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“Two out of the five studies tested discharge interventions that involved communication with the primary care physician.(22,24) The discharge summary documentation had no effect on outcomes,(22) while the multidisciplinary team intervention involving collaboration with the primary care Sawan et al.”
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Dementia Screening in Primary Care: Not Too Fast!
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Acceptability and Results of Dementia Screening Among Older Adults in the United States
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Digital Detection of Dementia in Primary Care
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Dementia Care Across a Tertiary Care Health System: What Exists Now and What Needs to Change
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Patient and caregiver outcomes at the integrated memory care clinic
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Models of Care for Older People: A Scoping Review
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Bending the Curve of Health Trajectories for Older Adults Discharged From the Emergency Department
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- Authors
- Boustani, M. A., Sachs, G. A., Alder, C. A., Munger, S., Schubert, C. C., Guerriero Austrom, M., Hake, A. M., Unverzagt, F. W., Farlow, M., Matthews, B. R., Perkins, A. J., Beck, R. A., & Callahan, C. M.
- Affiliations
- Regenstrief Institute (US)
- Indiana University Indianapolis (US)
- f Department of Psychiatry , Indiana University School of Medicine , Indianapolis , IN , USA
- Indiana University School of Medicine (US)
- Corresponding author
- Boustani, Malaz A.
- ORCID
- Venue
- Aging & Mental Health
- Publisher
- Informa UK Limited
- Published
- 2011-01
- Volume
- 15
- Issue
- 1
- Pages
- 13-22
- ISSN
- 1360-7863 (ISSN-L)
- 1364-6915
- PMC
- PMC3077086
- OpenAlex
- W2017215880
- Cited by
- 142
- References
- 26
- Citations by year
- 2026: 3 · 2025: 9 · 2024: 5 · 2023: 7 · 2022: 15 · 2021: 12 · 2020: 7 · 2019: 13 · 2018: 4 · 2017: 9 · 2016: 8 · 2015: 16 · 2014: 16 · 2013: 12 · 2012: 5
- FWCI
- 7.44
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Aging & Mental Health (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- IUScholarWorks (Indiana University) (submittedVersion)
- Funders
- National Institutes of Health
- School of Medicine, Indiana University
- National Institute on Aging (AG010133, P30AG010133, K24 AG026770, K24AG024078, K23AG026770, R01AG029884, P30AG024967)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Keywords
- dementia care, collaborative care, implementation science, complex adaptive systems, informal caregivers, emergency department visits, hospital readmission, anticholinergic agents, public health care system
- MeSH terms
- Aged, Aged, 80 and over, Aging, Community Mental Health Centers, Dementia, Female, Humans, Indiana, Interviews as Topic, Male, Middle Aged, Primary Health Care, Program Development, Models, Organizational, Patient-Centered Care, Organizational Case Studies, Quality Indicators, Health Care
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