JOHNS HOPKINS UNIVERSITY
Project Title: "Comprehensive home-based dementia care coordination for Medicare-Medicaid Dual Eligibles in Maryland"
Geographic Reach: Maryland
Estimated Funding Amount: $6,384,190
The Johns Hopkins University project will test the implementation of Maximizing Independence at Home (MIND), an Alzheimer's disease / Dementia (AD)-targeted care coordination model that systematically assesses and addresses the critical barriers to adults with AD remaining in their home. The target population is adults eligible for Medicare and Medicaid (Duals) in the Baltimore region. The model creates a broad link between community health agencies, medical providers and community resources, and innovatively synthesizes the expertise and experience of non-clinical community workers, nurses, physicians, and occupational therapists. Delivered over 18 months, MIND addresses 21 care need domains for patients and caregivers. The interdisciplinary team performs comprehensive, in-home, AD-related needs assessments followed by individualized care planning and implementation of six basic care strategies (resource referrals, environmental safety, dementia care education, behavior management skills training, informal counseling, problem-solving), on-going monitoring, and assessment and planning for emergent needs. Each component of the intervention is based on clinical practice guidelines and prior research, and is combined for maximum impact.