Studies show that supportive and authentic leadership and sponsorship, engaged and committed staff, multi-disciplinary team involvement, and a collaborative approach to work are indicators for success when making any sort of change in an organization.  

To accomplish this, it is important to engage in exploratory conversations with both leadership and frontline staff to gain insights into the organization’s priorities and needs. To ensure the success of any change, it is important that the proposed change meets a need, fulfills a requirement, demonstrates an added benefit for the organization, or ideally all three! 

When engaging in these conversations, think about challenging what you think you know and avoid falling into the assumptions trap. Ask questions to confirm your understanding and dig deep into orthodoxies of “what can never change” to identify why these sentiments exist.  

Some questions you might ask leadership:  

1. What are the top three priorities right now for this organization, and how do you see them evolving in the coming year? 
2. What are the biggest influences that shape how the organization sets priorities or goals? 
3. What are some key metrics that the organization is monitoring? 
4. In your view, how could a new program for screening older patients for dementia fit into our organizations currently priorities? 

Some questions you might ask frontline staff: 

1. What dementia care needs have you noticed for patients and their care partners? 
2. How equipped do you feel to provide screening and care planning for patients? 
3. What are the barriers to screening for dementia? 

Through conversations with staff or leadership, identify the people who have decision-making power in the area of influence over access to resources, and can help get things done.  

What is a champion? There are many ways to define a champion, but simply put, a champion is an advocate of a program or a cause who provides momentum and connections to ensure success. They are vital for ensuring practice change. Champions are generally passionate, motivated, positive thinkers, well-connected, action-oriented, and problem solvers.  Particularly around the change management issue that you are trying to address. 

Some questions to ask yourself and others in this process: 

1. Who is dependent on whom and for what resources? 
2. What layers of approval or dependencies exist? 
3. How do frontline and leadership interact and influence one another? 
4. Who makes financial decisions? 
5. Who are the key people to influence? 
6. What different approaches are needed for these audiences? 
7. What time and resources are available? 
8. Who in the organization will be most affected by this initiative? 

Now that you understand your organizational priorities and who you need to engage, you’re ready to match those needs with Dementia Care Aware program offerings and draft a high-level proposal to leadership. Be mindful of the scope and propose by starting small using a pilot approach.  

Disparities in Dementia

• The number of Californians aged 65 and older living with Alzheimer’s disease is expected to more than double by 2040 and specialist (neurology, geriatrics) capacity cannot support this alone. It is important that primary care be equipped to support this growing population and their needs. 
• Dementia Care Aware offers training, practice support, and resources to build capacity within the primary care setting to support this growing need. 
• The number of Black/African American, Latinx, AAPI, and LBGTQ Californians who are living with dementia will double or triple in number in the next 20 years (Latinx, AAPI, African American, LGBTQ) 
• Research shows that Californians who identify as Asian, Black, or Hispanic, for example, are less likely to receive a timely diagnosis of cognitive impairment compared with White Californians (Source) 
• A standard annual cognitive screen for all eligible patients reduces inequities of care. Dementia Care Aware offers tools and resources to help practices implement the cognitive health assessment as a standard annual screen to improve care for communities historically facing inequitable screening and diagnostic rates. 
• Qualifying CHA screenings are eligible for a $29 reimbursement under the new billing code CPT-4 code 1494F. Billing provider must complete the Dementia Care Aware cognitive health assessment (CHA) to use the billing code. 

Detecting Cognitive Impairment

• Detecting cognitive impairment is a required element of Medicare’s Annual Wellness Visit (AWV). Dementia Care Aware’s cognitive health assessment can be used during Medicare’s Annual Wellness visit to initially detect cognitive impairment.
• Medicare covers a separate visit to more thoroughly assess your patient’s cognitive function and develop a care plan – use CPT code 99483 to bill for this service.  As of January 1, 2024, Medicare pays approximately $268 (may be geographically adjusted) for these services when provided in an office setting. Learn more about when to use the CHA in our billing FAQ 

D-SNPs

• D-SNPs have robust reporting requirements for both Medicare and Medi-Cal. CMS requires several types of quality reporting for Medicare Advantage Plans including D-SNPs. This annual reporting includes a mild cognitive impairment measure of the number and percentage of patients over 65 whose cognition is assessed. 
• Dementia Care Aware’s cognitive health assessment is recommended for use to satisfy this requirement. 
• The CHA is also validated for use virtually/telephonically.  

Screening For Cognitive Impairment

• Screening for cognitive impairment allows for early interventions on modifiable risk factors such as hearing, vision, cardiovascular health, depression, etc. 
• Hearing aids reduced the rate of cognitive decline in older adults at high risk of dementia by almost 50% over a three-year period. (source)
• 61% higher prevalence of dementia among participants with moderate or severe hearing loss vs. normal hearing and 32% prevalence of dementia in those with moderate or severe hearing loss who used hearing aids (source)
• 30% reduced risk of dementia if depression is treated (source)
• A review of 18 randomized control trials in 2016 found that physical activity showed a positive effect on cognitive function with benefits seen both in those with and without Alzheimer’s disease.  The benefit was primarily observed with aerobic exercise. (source) 

Aducanumab and Lecanumab

• Aducanumab and Lecanumab are approved by the FDA to treat early Alzheimer’s disease, including those with mild cognitive impairment 
• A simulation study found that a hypothetical treatment innovation that delayed the onset of Alzheimer’s disease by 5 years would reduce the population with the disease by 41 percent in 2050, which would reduce annual costs by $640 billion (Zissimopoulos et al., 2014).
• Screening using the CHA can lead to an earlier diagnosis. This may benefit patients who are interested and eligible for novel treatment options, as those options are currently approved and most beneficial for those in the early stages of the disease.  

Managed Care Plans (MCPs) and Long-Term Care (LTC)

• Under CalAIM, Medi-Cal managed care plans (MCPs) will cover and coordinate Medi-Cal institutional Long-Term Care (LTC) in all counties in 2023 in a phased approach by facility type. 
• Residential care is very expensive. Estimates of the typical costs of long-term care range from $52,624 per year for a home health aide to $90,000 for a semiprivate room in a nursing home and up to $102,000 for a private room (Genworth Financial, 2020)
• Screening using the CHA can lead to an earlier diagnosis and allowing for earlier interventions of supports that allow for patients delay long term care needs and live independently. Reducing costs for managed care plans. 
• Participants of a dementia care program study received dementia care plans were less likely to be admitted to a long term care facility when compared to those not participating in the program https://pubmed.ncbi.nlm.nih.gov/30575846/ 

Licensed Providers

• Licensed providers must complete continuing education hours to maintain their licensure. Dementia Care Aware training and educational offerings provide FREE CE and CME/MOC  to help meet those requirements. 

Determine Next Steps 

You may be given a greenlight to move forward after engaging with leadership, however discussions may bring concerns, hesitancies, and barriers to the surface. 

If your initial proposal was not approved as is, take a step back and address any questions or concerns from leadership and work together with champions to come up with creative solutions. It could be that the pilot might need to wait until there is capacity in the organization, or that the proposal needs to be scoped down to a simpler approach to determine feasibility. Consider asking decision-makers what components are causing barriers or how do they envision a program like this being beneficial? From there, what is a pathway toward approval?

Whether you are starting from the ground up and adding the cognitive health assessment as a new clinical protocol or updating processes to be more comprehensive, it is important to set goals, measure progress and adjust milestones to understand if and how you were successful. 

Goals should account for staff capacity, patient population characteristics, the availability of community resources, existing clinic resources and partnerships, known areas of community need, and current screening practices.  

Before establishing final metrics first think through what you may want to measure that can signal success, this could be screening rates, the results of screening, etc. Dementia Care Aware has a list of potential metrics that you may use, but you can also choose whatever is right for your clinic.  

Once you have established what you’d like to collect, you should then determine what you currently can collect. It could be that processes are lacking or absent and need to be built out. Think about: 

• Which roles are currently performing the process of interest 
• How data is entered and/or collected. 
• Where those data are stored and retrieved. 
• How data is analyzed. 

Determine the Baseline and Set Goals 

Once you establish your measures it is important to determine the baseline upon which you will measure change For example, if you were interested in measuring screening rates, or the number of screens per month, it would be important to know how many screens were conducted before the start of the project. If the number of screens is not well understood or able to be easily measured before the start of the project, the baseline can be defined after the first few months of the project. 

Then you can set goals for what you would like to achieve in this project. At this step, it is important to start small and make sure all goals you set are SMART goals – meaning they are specific, measurable, achievable, relevant and time bound. Some examples include 

• All clinic staff will be informed of or trained on the CHA by June 30, 2024 

• • Specific = all clinic staff gives a denominator 
  • Measurable = Informed or trained provides a tangible intervention or training and/or communications 
  • Achievable = broad enough with a doable time frame 
  • Relevant = educated and trained staff facilitates confidence and competence 
  • Time Bound = clear end date of June 30, 2024 
• Improve current CHA screening rates by 15% by March 2025. 
  • Specific = Current CHA screening rates gives a denominator 
  • Measurable = 15% provides a tangible measure  
  • Achievable = broad enough with a doable time frame 
  • Relevant = increasing screening rates represents action toward timely identification of cognitive concerns and potential dementia
  • Time Bound = clear end date of March 2025

Continually Engage Staff and Stakeholders  

Finally, as you roll out the processes and changes, keep engaging with staff and stakeholders to review data and progress towards goals, making adjustments based on feedback. Utilize leadership meetings and staff huddles alike as a forum for these discussions. Adopt changes that work, adapt those that need some additional work, and abandon those that had no impact on the goals and outcomes. 

During discussions with frontline staff, elicit ideas and feedback from on how the process is working or not working for them, and request ideas for improvements, modifications, or updates. Transform these ideas into PDSAs or Plan, Do, Study, Act strategies to test ideas and interventions.   

During discussions with executive stakeholders, demonstrate progress towards goals, contextualize the benefit of the project relative to larger organizational goals and purpose, and update them on any improvements or course corrections in progress. Elicit their thoughts on how to better align the process with overarching organizational and care delivery goals. 

Dementia Care Aware understands that practice change is difficult to do without support. For organizations interested in hands-on guidance and connections to resources to make meaningful improvements in their daily practice, Dementia Care Aware has partnered with UCLA Health and the Alzheimer’s Association’s consultation and quality improvement team.

UCLA Health Alzheimer’s and Dementia Care (ADC) Program

Based on the award-winning UCLA Alzheimer’s and Dementia Care Program, this co-management model of care is designed to help patients and their families meet the complex medical, behavioral, and social needs of Alzheimer’s disease and other types of dementia.

Benefits of adopting the ADC program:

• 40% reduction in long-term nursing home placement
• 64% reduction in behavioral symptoms
• 79% improvement in caregiver confidence in handling dementia complications
• 61% reduction in caregiver stress
• 92% of dementia quality indicators are met
• $2,404 Medicare savings per year per patient

Physician post-ADC adoption survey results:

• 72% felt they received valuable social recommendations
• 71% felt they received valuable behavioral recommendations
• 89% felt their relationships with patients were enhanced
• 82% felt they saved time
• 100% of providers would recommend the ADC to other patients

UCLA Health ADC Program Flyer

UCLA Health ADC Guide Model Flyer

UCLA Health Dementia Care Aware Offerings

As part of the Dementia Care Aware initiative, UCLA Health is providing several key offerings. UCLA’s role is to improve the care and outcomes of persons living with dementia (PLWD) and their caregiver after diagnosis. UCLA plans to do this by providing training and support to healthcare providers and assistance with practice-level changes to have the needs of PLWD addressed systematically through comprehensive dementia care programs.

Contact Program Manager Jagrup Kaur for more information about UCLA Health’s ADC Program and Dementia Care Aware key offerings.

UCLA Health Dementia Care Aware Program Flyer

The Alzheimer’s Association

Transformative Consulting Services

From assessment and diagnosis to care planning and follow-up, the Alzheimer’s Association will work with your health system to transform your dementia care practice. Through our consulting services, we can:

• Analyze data to uncover barriers to quality dementia care
• Provide tools and resources to implement evidence-based strategies
• Perform a gap analysis to identify key areas for process and quality improvement
• Use Triple Aim to optimize health systems performance
• Develop customized solutions to help improve dementia care management

Quality Improvement Services

Alzheimer’s Association staff can serve as consultants and/or facilitators on formal QI projects designed to address the unique challenges of your health system, primary care practice or organization. Through strategies such as staff training and guidance on the implementation of evidence-based tools and resources, the Association can help you:

• Reduce inefficiencies in process and workflow
• Implement and improve practice standards for person-centered dementia care
• Enhance the quality of care and potentially reduce costs

Alzheimer’s Association Health Systems Consultation Services Flyer

Contact hsdca@alz.org for more information about the Alzheimer’s Association Health Systems support services.