Piloting the MIND at Home Dementia Care Navigation Program in primary care

INTRODUCTION: Persons living with dementia (PLWDs) have complex needs and high expenses, and primary care (PC) plays a key role in their care. However, few American PLWDs receive adequate care, and many have unmet but potentially modifiable dementia-related care needs. Embedding effective evidence-based care strategies into PC settings is an opportunity to reduce excess burden but remains rare. This study evaluated the feasibility and potential impact of adapting and implementing the MIND at Home Dementia Care Navigation Program (MIND at Home) into PC at two large unique health systems in the United States. METHODS: A pilot pragmatic clinical trial evaluated the feasibility and potential impact of integrating MIND at Home into primary care. Process measures included identifying and addressing a comprehensive set of dementia-related needs for PLWDs and care partners, conducting home visits, and capturing clinic-based outcomes such as hospital transfers and medications. Data were collected on intervention patients, with additional data obtained for a validation group within the health systems based on eligibility criteria. RESULTS: A total of 105 PLWD-care partners (dyads) were enrolled for a 3-month intervention period. All dyads received a comprehensive needs assessment, a personalized care plan, and care navigation. Seventy-four percent of identified needs were addressed. Health care utilization measures were feasible to collect from both sites, based on validation data. Medication data were collected but were difficult to interpret. DISCUSSION: MIND at Home was successfully implemented into the PC setting and key outcomes were ascertained using electronic health record data. A comprehensive evidence-based approach that combines the benefits of clinic-based health care and home-based supportive services for PLWDs, their families, and their care partners has the potential to reduce unmet care needs and reduce hospitalizations. Observed trends in hospital transfers suggest a potential association that warrants further investigation, especially among PLWDs with more advanced dementia. Highlights: Persons with dementia and their care partners receive fragmented, suboptimal care and support.The MIND at Home Dementia Care Navigation Program (MIND at Home) provides a solution by adding home-based assessments and primary care (PC) integration.MIND at Home was embedded successfully into PC with fidelity into two health systems.Patient and care partner needs were identified and addressed via a care plan.Key utilization outcomes were ascertained using electronic health record data.