Health Care Innovation Awards Round Two: Regents of the University of California San Francisco Project Profile

Project Title: "The UCSF and UNMC Dementia Care Ecosystem: Using Innovative Technologies to Personalize and Deliver Coordinated Dementia Care"
Geographic Reach: California, Nebraska
Estimated Funding Amount: $9,990,848

Summary:

The Regents of the University of California San Francisco project will implement Care Ecosystem, an innovative clinical program that builds on the UCSF Memory and Aging Center's 15-year history of offering high-quality dementia care, while incorporating the University of Nebraska Medical Center's specialized expertise in functional monitoring and rural dementia care. Whereas most dementia care today is crisis-oriented and reactive, this model emphasizes continuous and personalized care. The target population is Medicare beneficiaries and persons dually eligible for Medicare and Medicaid. By supporting family caregivers, keeping patients healthy, and helping them prepare together for advancing illness, this model aims to improve satisfaction with care, prevent emergency-related health care costs, and keep patients in the home longer. The primary point of contact for patients and families will be a Care Team Navigator (CTN) with 24/7 availability. An innovative "dashboard" with both CTN and patient portals will drive efficient and personalized communication between the CTN, care team, and the patient and family. The 4 modules of Care Ecosystem are as follows. The Caregiver Module will include educational forums and connect families with community resources. The Decision-Making Module will facilitate proactive medical, financial, and safety decisions. The Medication Module will track and reduce inappropriate medications or doses and trigger a pharmacist review when indicated. The Functional Monitoring module will use smartphones and sensors to rapidly detect and respond to changes in functional status, which is particularly important for patients living remotely, alone, or who are at-risk for acute declines.

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