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Population‐based Dementia Identification and Care Coordination: The CS CARES Program
Zaldy Sy Tan, Nabeel Qureshi, Sarah A. Kremen, Deana Rhinehart, Dyane Gatmaitan, Erica Spivack, Augustine Guinto, Nancy L. Sicotte. Alzheimer s & Dementia, 2023-12-01
Topic: Risk, prevention and care in population studies
Abstract Background Alzheimer’s disease and related dementias (ADRD) afflict over five million persons in the U.S., and persons living with dementia (PLWD) have been shown to receive poor quality care and experience worse health outcomes compared to those without ADRD. While dementia care programs have been shown to improve these outcomes, to date, the effects have not been studied in a value‐based Medicare population. Methods In a large multi‐specialty medical group practice, we identified patients enrolled in a value‐based insurance program (Medicare Advantage) using the EPIC electronic health record (EHR). Patients were eligible to enroll in a care coordination program if they had an ICD‐10 diagnosis of ADRD in the EHR problem list and/or past medical history, or currently taking an FDA‐approved medication for ADRD. We invited eligible patients to enroll in the CARES dementia care program and additionally included patients with ADRD who have a primary care provider in the health system. A study‐assigned nurse practitioner (NP) identified the patient’s medical, behavioral, and psychosocial needs using the novel CEDARS‐6 dementia care tool to formulate and share a care plan with the patient’s primary care provider. Regular check‐in calls were scheduled, and care plans were updated based on patient’s status. To evaluate patient and caregiver baseline health status, we assessed patient behavior (NPI‐Q), caregiver stress [Modified Caregiver Strain Index (MCSI)], and caregiver depression (PHQ‐9). Results We enrolled 195 (33.1%) of eligible patients, with non‐responders to the invitation accounting for the majority (75%) of non‐enrollees. The average age of enrollees was 81.3 (SD = 9.16) years old, 64.6% were female, and 81.2% identified English as their primary language. Based on caregiver report, patients scored an average NPI‐Q Severity score of 10.40 (6.87), and an average NPI‐Q Distress score of 13.80 (10.54). Caregivers scored an average PHQ‐9 score of 5.65 (5.28) and MCSI score of 10.62 (7.01). Conclusion PLWD proactively enrolled in a dementia care program have high baseline rates of behavioral issues and their caregivers have elevated depression and stress scores. It is important to track the longitudinal effects of the CARES dementia program on these measures.
Key findings
- Abstract Background Alzheimer’s disease and related dementias (ADRD) afflict over five million persons in the U.S., and persons living with dementia (PLWD) have been shown to receive poor quality care and experience worse health outcomes compared to those without ADRD.
- Results We enrolled 195 (33.1%) of eligible patients, with non‐responders to the invitation accounting for the majority (75%) of non‐enrollees.
Why it matters
In a value-based Medicare Advantage population, 195 of eligible patients (33.1%) enrolled in a dementia care coordination program in which a nurse practitioner assessed needs and shared care plans with primary care providers. This is an early report on program enrollment and care coordination, not on treating, curing or preventing Alzheimer's disease.
Study details
- Study designlongitudinal study
- Participants195
- Effect size33.1%; 64.6%; 81.2%
- Evidence strengthModerate
How this study scored 46/100
Published in a peer-reviewed journal, and it is a longitudinal study following the same people over time. Scored zero for randomised / blinded because the record does not state it.
| Component | Points | Why |
|---|---|---|
| Journal tier | 7 / 10 | Tier 3 — peer-reviewed journal (Alzheimer s & Dementia) |
| Journal's citation record | 2 / 4 | Alzheimer s & Dementia: journal h-index 228 (OpenAlex, 2026-10-29) |
| Study design | 7 / 12 | A longitudinal study following the same people over time |
| Strength of evidence | 3 / 5 | Rated “moderate” in our summary |
| Peer-review validation | 10 / 10 | Peer-reviewed. Published as an article in a named peer-reviewed journal. |
| How recent | 3 / 5 | 2023 — within 6 year(s) of the newest study here |
| Sample size | 2 / 4 | 195 participants |
| Effect reported | 2 / 3 | Effect reported as a number, without an interval or test |
| Studied in people | 3 / 3 | Studied in people (participant count stated) |
| Randomised / blinded | 0 / 2 | No randomisation or blinding stated — scores zero (not stated in the record — scored 0) |
| Times cited | 0 / 7 | Cited 0 times (OpenAlex, 2026-10-10) |
| Citations per year | 0 / 5 | 0.0 citations a year over 5 year(s) since 2023 |
| Impact for its field and year | 0 / 6 | Cited 0.0× the average for papers of its field and year (OpenAlex FWCI) |
| Cited by studies here | 0 / 6 | No other study in this library cites it |
| Still being cited | 0 / 4 | Cited 0 times in 2024–2026 (2026 still in progress; OpenAlex) |
| Senior author's track record | 2 / 4 | Last-listed author Nancy L. Sicotte: h-index 48 (OpenAlex, whole career) |
| Institution's track record | 1 / 3 | Cedars-Sinai Medical Center: institution h-index 866 (OpenAlex) |
| Multi-centre collaboration | 1 / 3 | OpenAlex lists 2 institution(s) in 1 country |
| Indexed in PubMed | 1 / 2 | Not in PubMed, but has a DOI |
| Free to read | 2 / 2 | Free to read |
| Total | 46 / 100 | — |
What each of these 20 components measures, and what this score is not →
Read the original
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Cite this study APA, Vancouver, BibTeX · download .bib or .ris
Built from the record alzhub holds for this paper, not looked up. Volume, issue and page numbers are not held in the record. The record names 8 authors; APA and Vancouver show the first six, BibTeX and the downloads carry all of them. Check the citation against the original before you use it.
APA 7th
Tan, Z. S., Qureshi, N., Kremen, S. A., Rhinehart, D., Gatmaitan, D., Spivack, E., et al. (2023). Population‐based Dementia Identification and Care Coordination: The CS CARES Program. Alzheimer s & Dementia. https://doi.org/10.1002/alz.077529
Vancouver
Tan ZS, Qureshi N, Kremen SA, Rhinehart D, Gatmaitan D, Spivack E, et al. Population‐based Dementia Identification and Care Coordination: The CS CARES Program. Alzheimer s & Dementia. 2023. doi:10.1002/alz.077529.
BibTeX
@article{tan2023-fe172fcd,
author = {Tan, Zaldy Sy and Qureshi, Nabeel and Kremen, Sarah A. and Rhinehart, Deana and Gatmaitan, Dyane and Spivack, Erica and Guinto, Augustine and Sicotte, Nancy L.},
title = {{Population‐based Dementia Identification and Care Coordination: The CS CARES Program}},
journal = {Alzheimer s \& Dementia},
year = {2023},
doi = {10.1002/alz.077529},
url = {https://doi.org/10.1002/alz.077529}
}