Improving dementia care at Providence with an innovative, evidence-based model

Tuesday, September 26, 2023

Authors: Nick Olney, M.D., medical director, Providence Care Ecosystem
Mary Beth Kuebrich, AGPCNP, clinical lead, Providence Care Ecosystem


About 6.7 million people in the U.S. live with Alzheimer’s and related dementias. September is World Alzheimer’s Month, a time to raise awareness of Alzheimer’s and other dementias and to advocate for innovative care models.

Over 16 million people – spouses, adult children, neighbors – provide unpaid care to support them. As a result, these care partners:

  • Experience mental and emotional strain directly related to caregiving, with depression affecting 30-40% and anxiety affecting 44% of dementia care partners
  • Face financial challenges because of missed work, high costs of care and declines in their own health as a result of caregiving
  • May encounter barriers to care and disproportionate burdens if they are people of color or members of the LGBTQ community

In addition, health care systems struggle to meet the medical and non-medical needs of this population, resulting in overburdened primary care practices, constrained specialty access and inappropriate utilization of emergency departments.

Creating innovation solutions
Providence is working to address these challenges by implementing age-friendly care strategies focused on high-value care for older adults. A crucial part of this strategy is the dementia Care Ecosystem program.

The Care Ecosystem model began at University of California San Francisco and came to Providence in 2021 as a donor-funded pilot program. The program is operated as a partnership between Providence Brain and Spine Institute and Providence Senior Health. In 2022, Providence joined a six-site National Institutes of Health (NIH) research grant to track the program’s clinical and cost outcomes.

How Care Ecosystem works
Jamal and Amy* were one of the first families referred to the Providence program.

The couple lived independently, and Jamal made it clear that he wanted to care for Amy at home for as long as possible. Care Ecosystem navigators are assigned to those who are eligible to receive services.

The navigators are extensively trained in dementia care and are supported by an interdisciplinary team from geriatrics, neurology, pharmacy, nursing and social work. A typical check-in might include reviewing high-risk medications, providing home safety tips, sharing community-based resources, coaching caregivers on behavior management strategies and more.

“With time and my consistent outreach calls, we built a trusting relationship,” says Sidney Chanthavong, navigator for Jamal and Amy. “He often called me during times of crisis or when he just needed someone to talk to.”

When Amy’s behavioral distress escalated, Jamal knew he could contact Sidney for support and advice. This unique approach is precisely what makes Care Ecosystem successful. After Amy died peacefully, Jamal said to Sidney, "I couldn’t have taken good care of Amy without you and [Amy’s PCP], so I thank you both so much.”

Care model of the future
Multiple studies have demonstrated the impact of Care Ecosystem and similar dementia navigation programs. Not only does it improve care and quality of life for patients and families, it also reduces time and cost burdens for providers and health care systems.

Providence’s pilot data align with these findings, showing a statistically significant decrease in both inpatient and outpatient visits among participants. The Providence team recently added a bilingual navigator to support the Spanish-speaking community.

Care Ecosystem and similar dementia navigation programs also are growing and gaining traction nationally. A recent announcement from the U.S. Centers for Medicare & Medicaid Services highlighted the potential of such programs to meet the growing demand for affordable, high-quality, culturally relevant dementia care.

Notes: Care Ecosystem has specific eligibility criteria related to the NIH grant, with enrollment currently limited to PMG clinics at Hood River, Gateway, Gresham, Northeast, Plaza, Seaside and Warrenton.

*Participant names have been changed for this story to protect their privacy.

Additional resources

  • For more information on Providence Care Ecosystem, contact [email protected]
  • “Help is Here: When Someone You Love Has Dementia” provides support for family caregivers of people with dementia, written by Marian O. Hodges, M.D., and Anne P. Hill. Copies are available in English and Spanish. See Help is Here Guidebooks | Providence for more information, or contact [email protected] for assistance in ordering for clinics.
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