Disparity populations, in particular aging African-Americans and Hispanics (65 years and older), are significantly more likely to have Alzheimer?s disease and related dementia (ADRD) than older Whites in the same age range. Delays in accessing timely primary care, lack of care coordination, and variations in lifestyle and socioeconomic conditions are considered as major factors that contribute to racial and ethnic disparities. Health care coordination, such as chronic care management and post-hospital discharge continuity of care programs, has been identified as a critical component in improving quality of care and patient experience. In addition, Accountable Care Organizations (ACOs) have been proposed to promote care coordination through team-based approaches and financial incentives. However, little is known about how these system-level care coordination strategies have improved health care access, quality and equity for populations with ADRD. The objective of our project is to determine best hospital-community care coordination practices that can improve effective management of ADRD and co-existing conditions; control/reduce modifiable risk factors of ADRD and administer health care for these diseases in early stages; and eventually promote population health and reduce health disparities. Our primary hypothesis is that integrating hospital and community care can improve quality and equity among people with ADRD as well as cognitively healthy older adults at increased risk for ADRD. We will leverage our comprehensive, national data on care coordination, and construct a multi-level data set (individual-, hospital/ACO-, community-, and state- level) by linking Medicare claims data and Shared Savings Program Accountable Care Organizations data to address our primary hypothesis. Using a population-level longitudinal study (2012-2018), we aim to identify the influences of care coordination practices and ACOs on health care access, quality, and cost for people with ADRD and older adults at increased risk for ADRD (including adults living with diabetes, hypertension, high cholesterol, obesity, smoking, and mild cognitive impairment) (Aims 1 and 2); estimate the impact of care coordination on one of the hardest-to-reach populations: racial and ethnic minority populations who received federal housing assistance (who may have experienced periods of homelessness) (Aim 3); and highlight care coordination practices and the ACO models that can reduce racial and ethnic disparities (Aim 4). Our multidisciplinary, systems-based approach will enable us to identify the most critical care coordination practices that will have the greatest impact on increasing effective care for minority patients with ADRD; and control diseases in early stages among those with ADRD risk factors. Our results will provide policy makers with critical information on how to utilize existing resources to integrate care coordination across the health care system to ensure that minorities get access to the most appropriate and effective care. The goal aligns with the National Plan to Address Alzheimer's Disease that aims to enhance care quality and efficiency.
The proposed research is relevant to public health because results will identify care coordination practices and ACO structures that can promote health care access and quality for people with risk factors or diagnosis of ADRD, with a focus on African Americans, Latinos, and the hardest-to-reach Housing and Urban Development (HUD) population. Results of our study are expected to provide evidence on cost-effective care coordination practices that can make care integration sustainable for underserved populations. Thus, the proposed research is relevant to the NIA?s mission (PAR-18-596): ?to consider how institutional and social contexts influence disparities in service access and quality; and identify how regulatory and economic incentives affect access, quality, and health outcomes in health systems for people with dementia.?
