Program overview: The Dementia Care Coordination Program is an evidence-informed intervention based on a Veterans Administration demonstration study that showed improved outcomes and decreased utilization. The program is administered in partnership between a vendor and the health plan. The program is designed to assist caregivers in managing Alzheimer’s disease and related dementias.

The Dementia Care Coordination Program is a referral-based program that works as follows:

• Referrals are typically initiated by the member’s PCP or other treating provider’s care manager. The care manager and/or other identified referral source makes a secure referral to the vendor via fax, email or a HIPAA-compliant online form
• The vendor will have a master’s level social worker (a memory specialist) makes a proactive call to the family caregiver to schedule a care consultation within five to seven days from date of referral. The consultation is personalized and usually an hour long followed by a written care plan sent to the caregiver and a summary of the care plan sent to the referrer as well as the primary care physician if the family allows.
• The program is focused on providing the caregiver with strategies and resources to increase their chance of success in caring for their loved one.
• The full program lasts for approximately six months. A total of three calls are made to the caregiver during the six-month timeframe to assess progress and provide resources as needed.