Q & A with David B. Reuben, MD Director, Multicampus Program in Geriatric Medicine and Gerontology, Chief, Division of Geriatrics, University of California, Los Angeles

You are a member of the Milken Institute Alliance to Improve Dementia Care. Describe the expertise that you bring to the Alliance and how the ideas explored during our convenings have helped inform your work.

Much of my work over the past decade has focused on creating, implementing, and testing new models of care for people living with dementia and their caregivers. My first-hand experience working within a major academic health system and with numerous external health-care systems has given me deep perspective on the barriers and facilitators to implementing changes to improve dementia care. This work has been pragmatic, real world, and evidence-based.

Individuals living with dementia have complex medical and psychosocial needs that are often not met. Could you describe how a population-health approach to delivering comprehensive dementia care can improve quality of life for people living with dementia and their caregivers and help reduce the cost of care?

The population of people living with dementia who are cared for by any health system includes a wide range of disease stages and complications. The challenge is matching services and care provided to individuals’ needs. Providing too little care for those who have high needs is likely to result in poor quality, worse clinical outcomes, and higher costs. Conversely, providing too much care for those who have few needs is wasteful. Hence, a diverse array of services is needed, and a system of triaging patients to the appropriate care for their particular needs and resources must be developed.

People living with dementia and their caregivers must navigate complex and fragmented health-care and long-term services and support systems to receive quality care after a diagnosis. What must be done to promote a more seamless, coordinated patient experience?

Care for people living with dementia and their caregivers may range from simply information-giving for those with mild disease to very complex, highly intense care, including both health care and community-based social services, to those with severe disease or complications. Therefore, having staff who can help those affected by directing them to specific services and facilitating the receipt of these services, which may be housed outside of health-care systems, is essential. For those who have mild disease and few complications, this may be achievable with an unlicensed staff who have solid knowledge about resources both within the health-care system and in the community. For those who have severe disease or complications, particularly behavioral complications, higher levels of proactive care coordination and intensive management are necessary.

Describe the work UCLA is doing to improve access to high-quality care for individuals living with dementia and their caregivers. How are current Medicare reimbursement policies impacting your ability to deliver components of comprehensive care?

UCLA is working at three levels to improve high-quality care for individuals living with dementia and their caregivers. First, we are continuing to expand services, including algorithms that use electronic health record data to generate recommendations for primary care physicians to refer patients to appropriate services, many of which are not dementia-specific (e.g., palliative care, clinical pharmacy, pelvic health). Second, we continue to expand the services of the UCLA Alzheimer’s and Dementia Care Program to better meet the needs of our patients and increase the efficiency of services. Third, we are disseminating the core elements of the UCLA Alzheimer’s and Dementia Care Program to health-care systems nationwide. To date, 18 health systems have adopted the model and modified it to local workflow, staffing, and culture. In addition, we are testing health system-based dementia care compared to community-based dementia care compared to usual care in a large, multisite, pragmatic trial.

Given the multi-sector membership and focus of the Alliance to Improve Dementia Care, what are you hopeful about over the next 5 to 10 years?

Because of its diverse and enthusiastic membership, I believe that the Alliance to Improve Dementia Care has substantial potential to spark the necessary changes including adequate payment for high-quality dementia care, dissemination of successful models, identification of additional needs (e.g., training), and sharing of best practices. I am hopeful that, within five years, high-quality dementia care will be disseminated nationwide, not just confined to a few innovative health systems. The need is great; the time is now.