Interprofessional Team-Based Dementia Care: Integrating Professional, Health System, and Community Resources

Alzheimer disease (AD) has long been recognized as a growing public health problem worldwide. Multiple factors likely will bring this to a crisis point for the US health care system throughout the 2020s and beyond. AD and other dementia-causing illnesses are age-related conditions, and the US population older than 65 is projected to expand by more than 1 million people per year over the next 40 years. Accurate blood-based biomarker testing for AD pathology is available and with improving predictive value will be used increasingly in clinical settings. This will be true especially among individuals with milder symptoms not yet reaching the threshold for dementia diagnosis, such as with mild cognitive impairment (MCI). Food and Drug Administration (FDA)–approved disease modifying therapies (DMT) for AD exist and likely will become widely used. Their approved indications include MCI caused by AD, suggesting that more than 20% of the US population older than 65 years might be considered for anti-AD therapies.1 This markedly expands the number of people potentially eligible for DMT for AD. Furthermore, DMT most likely will prolong the duration of the symptomatic illness, further enlarging the pool of people with cognitive impairment.

Because AD is a degenerative brain disease, neurologists are the de facto dementia specialists in most communities. However, even before the AD population expanded and AD treatments became available, neurology was already experiencing a workforce shortage, which is projected to continue to worsen.^2-4 Neurologists, individually and collectively, cannot be expected to absorb the unrelenting growth in the number of people diagnosed with AD or MCI, manage the expanded use of DMT, and navigate the overall complexity of dementia care.

Meeting the Needs of Persons with Dementia

Most unmet needs in dementia care are not neurologic in nature. A survey among families facing dementia indicated unmet needs related to support in home and personal safety, daily activities, legal assistance and advance care planning, and care financing rather than cognitive symptom management—the traditional postdiagnostic role of neurology.⁵ Addressing these complex social, emotional, and physical care needs requires the assistance of a wide range of health care team members. Table 1 identifies common needs experienced by persons with dementia and the health care team members with the expertise to address them.

It can be a challenge to connect the affected person and caregiver with needed services. Access is often limited to what is available in a specific region as well as the affected person’s financial and personal resources. In addition, collaborating with various health care team members is time-consuming. Providers in primary care practices face similar challenges when caring for people who experience behavioral health issues, such as depression, anxiety, or substance abuse. To address this, a model for integrated care of AD is emerging based on existing collaborative care models as described here.

Behavioral Health Integration

Behavioral health integration is a systematic approach to care in which the primary or specialty care provider collaborates with behavioral health clinicians to provide patient-centered care that increases positive outcomes and improves overall health.⁶ Originally conceived as a strategy to address health issues in persons living with a psychiatric or substance use disorder, this approach is applicable to managing the behaviors and issues that affect the well-being of persons living with dementia and their caregivers.

Types of Models and Outcomes

Behavioral health integration models vary based on the extent of collaboration among health care team members. Levels of integration are illustrated in Table 2. A common model for behavioral health integration is the collaborative care model, a strategy originally developed to treat depression in primary care. In this model, a behavioral health specialist collaborates with a primary care provider to screen for and treat psychiatric disorders. The behavioral health specialists’ qualifications and scope of practice may vary but typically include prescribers, such as physicians and advanced practice providers, or social workers and registered nurses, who act as case managers. The key to collaborative care model success is proximity of behavioral health services to the practice setting; coordinated care management by a nurse, social worker, or other qualified behaviorist; ongoing behavioral symptom monitoring by the care manager during office visits or by phone; and use of brief behavioral interventions to manage symptoms as they emerge.⁷

Dementia-specific models for behavioral health integration are emerging. For example, dementia care management (DCM), a collaborative care model that uses dementia-specific trained nurses as care managers, is designed to provide caregiver support and optimal treatment for persons with dementia in primary care settings.⁸ The outcomes of DCM included decreased behavioral and psychological symptoms and reduced caregiver burden. Additional benefits of this model include improved quality of life for persons who were not living alone when cared for and decreased health care costs attributable to lower hospitalization rates and delayed entry into long-term care.⁹

Collaborative dementia care can be delivered effectively by telephone and the Internet using a trained navigator who provides patient education, patient and caregiver support, and care coordination with a team of dementia specialists to patients over a broad geographic area.¹⁰ Telehealth approaches expanded rapidly during the COVID-19 pandemic. Today, there is an increasing reliance on telemedicine to care for older adults with cognitive impairment.¹¹ Success in using this approach hinges on a variety of factors, including availability of telemedicine technology and the skill of the clinician, staff, patient, and caregivers in using the technology. Current Procedural Terminology (CPT) code 99483, “Cognitive Assessment & Care Plan Services,” can facilitate reimbursement for these more comprehensive dementia care services, as the code has been approved for both in-person and telehealth use. Although provider interaction with the patient and independent historian is required, data to support compliance with the documentation to support this CPT code can be collected by trained office staff for review, integration, and interpretation by qualified providers (ie, physicians, nurse practitioners, clinical nurse specialists, and physician assistants).¹²

Application to Neurology Practices

In the DMT era of AD, neurologists likely will be increasingly involved in the ongoing and longitudinal care of people with dementia. Anticipating the need to adapt practices and health systems to accommodate the ongoing needs of this patient population is important. Availability of dementia-specific care management services varies by geographic area and locating help for those who live in remote areas can be a challenge. Local and state health departments can be a good resource to identify referral paths to care management. Insurers also may provide care management services to the program enrollees as a means of controlling costs and improving outcomes. Depending on the model of care chosen and resources available in the community (such as local chapters of the Alzheimer’s Association), neurologists may need to consider hiring care managers in the practice or referring out to this service. Local or regional health systems may employ care managers as part of their ambulatory service, which can be expanded to include more dementia-specific expertise.

A systematic framework to help health care organizations prepare for the DMT era has been developed, but challenges in implementation have been reported.¹³ Neurologists have negotiated successfully for dementia care management implementation in health systems. Both clinical and administrative champions typically are required for health systems to sustain the upfront costs of such care management programs,¹³ but longer-term cost-utility of these approaches is supported by the literature.¹⁴

Summary

DMT for AD is a long sought-after goal and appears to be moving to widespread use. These treatments will have widespread and long-lasting effects on national health care systems and on neurologists.³ Because DMTs will not eliminate symptomatic AD, well-informed neurologists with thorough knowledge of local resources will play an important role in addressing the complex and changing unmet needs of people with dementia and their caregivers.