UCSF’s Care Ecosystem reduces dangerous medication use in dementia patients

Update: August 2023

In response to these pioneering efforts at UCSF, Medicare has taken a momentous step toward making quality dementia care available more broadly across the United States with the release of the GUIDE payment model.

Designed to support the UCSF Care Ecosystem and similar models of comprehensive, collaborative dementia care, health systems offering GUIDE will receive a lump sum for all Medicare Fee-for-Service (FFS) patients enrolled, starting July 2024.

The move will provide care navigation services that improve quality of life and reduce health care costs, benefiting not only people living with dementia, but also their caregivers.

“We realized that for a dementia care payment model to be meaningful it needed to address and prioritize the needs of caregivers,” said Katherine Possin, PhD, faculty member in the UCSF School of Medicine Department of Neurology, who is among the cofounders of the Care Ecosystem. “But this was a radical concept. Fortunately, Medicare has embraced it in GUIDE.

“GUIDE requires medication review and support—an important evolution that recognizes the innovative practice models developed by pharmacy faculty with geriatric expertise,” Possin said. “I would not be surprised if the decision to include this requirement was made in part because of the impactful work of Kirby Lee and Shalini Lynch,” faculty members in the Department of Clinical Pharmacy.

A routine medication review goes a long way toward helping people with dementia who live at home, according to UCSF experts. Recent findings show that medication oversight from a pharmacist, as part of a dedicated interprofessional health care team, reduces the use of dangerous prescriptions while upholding a higher quality of life for both dementia patients and their caregivers.

The study, published on November 4 in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, used a randomized control trial to demonstrate the benefits of including pharmacists in the health care team of the Care Ecosystem, a model of dementia care pioneered at UCSF. Compared to usual care, dementia patients who were assigned to the Care Ecosystem were less likely to be prescribed high-risk or inappropriate medications.

By working directly with patients, their caregivers, and providers, the Care Ecosystem can make a big difference in outcomes, said Kirby Lee, PharmD, senior author on the study and an emeritus faculty member in the UCSF School of Pharmacy’s Department of Clinical Pharmacy.

“Our team has an ongoing relationship that enables us to iterate and optimize care for each patient,” said Lee. “I think that’s what makes us pretty darn effective.”

An ecosystem of care for people living with dementia

The crux of the Care Ecosystem is a team of full-time, trained care navigators, each of whom is assigned dozens of dementia patients and their caregivers to provide a trustworthy link to the support that patients need. These care navigators coordinate between caregivers; primary care providers and specialists who have prescribing power; and the Care Ecosystem advisory team of pharmacists, nurses, and social workers.

Lee and Possin

Kirby Lee, PharmD, left, and Katherine Possin, PhD.

“Our care team navigators serve as the central hub, coordinating with our clinical team to have an ongoing dialogue about a patient’s care, whether it’s caregiving issues, financial issues, safety issues, or medication issues,” said Lee. “That whole comprehensive continuity of care is why we can move the needle and decrease the use of inappropriate medications.”

This high-touch approach—which involves monthly phone calls between caregivers and care team navigators—is crucial for proactively addressing health or behavioral problems, which are common in dementia patients, according to coauthor Katherine Possin, PhD, faculty member in the UCSF Department of Neurology, who cofounded the Care Ecosystem with Lee and others seven years ago.

“Caregivers need a primary point of contact in the medical system, so they can pick up the phone, call that person they know, and get some help,” said Possin. “It could be something as simple as ‘Can you help me troubleshoot how to deal with my wife’s incontinence,’ or it could be, ‘I really am not sure which of these medications she’s supposed to be taking.’”

Tackling the unique challenges of medication use for dementia

Prior research showed that the Care Ecosystem’s monthly check-ins and clinician oversight led to reduced emergency room visits for the patient as well as reduced depression and work burden for caregivers. In the new study, Lee wanted to measure the impact of the Care Ecosystem specifically on patients’ medication use over the course of twelve months.

“In general, dementia patients are prescribed more risky and problematic medications than other patients, not so much from issues with memory, but often due to behavioral challenges, like agitation, aggression, anxiety, insomnia, and depression,” said Lee. “And that's where this patient population is more concerning, presenting a much higher need for medication reviews.”

A flowchart depicting communication between a patient/caregiver dyad, care team navigator, prescribing provider, and pharmacist and clinical team
Alzheimer’s and Dementia

Flowchart of the Care Ecosystem medication review intervention and monitoring process.

Other approaches for decreasing inappropriate medication use were not as successful, according to Lee, because they did not provide safer alternative drug and non-drug strategies to prescribers and caregivers for helping their loved ones with dementia.

The Care Ecosystem, in contrast, brought together an interprofessional team, including a pharmacist, to come up with long-term solutions for each patient’s particular case, as relayed by the care team navigators, whether it was a lower dose, a different medication, or a behavioral or psychological approach. And then, a month later, they’d follow up.

“You could just tell a provider, ‘Don't prescribe an anti-psychotic,’ but how does that help when the patient is causing problems at home because he’s agitated?” said Possin. “Instead, our care team navigators and clinical team will think about behavioral strategies or changes to the environment, and try all the non-pharmacological approaches with the family at the same time as thinking about how to reduce those dangerous medications.”

In addition to reducing problematic medications prescribed to enrolled patients, the Care Ecosystem also made it more likely that patients had their anti-dementia medication regimens adjusted—a crucial component of effective treatment for the behavioral and psychological symptoms of these diseases.

Bringing the Care Ecosystem to all

Twenty health care institutions across the United States now utilize the Care Ecosystem to help people living with dementia, according to Possin, but like UCSF’s program, most of their funding comes from grants and philanthropy. Thankfully, insurance providers including Medicare are taking note of the model of care and just how cost effective it is. Possin and Lee both envision a future where such care is the norm.

Given just how prevalent dementia is, and how many of these patients live at home, the help couldn’t come any sooner.

“Our program is the right combination of human touch and health care expertise,” said Lee. “We really must get good quality dementia care to all who need it.”

Shalini Lynch, PharmD, faculty member in the Department of Clinical Pharmacy, also contributed to the recent work.


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About the School: The UCSF School of Pharmacy aims to solve the most pressing health care problems and strives to ensure that each patient receives the safest, most effective treatments. Our discoveries seed the development of novel therapies, and our researchers consistently lead the nation in NIH funding. The School’s doctor of pharmacy (PharmD) degree program, with its unique emphasis on scientific thinking, prepares students to be critical thinkers and leaders in their field.