# The Care Ecosystem: Navigating patients and caregivers through stages of dementia care

> **NIH NIH R01** · UNIVERSITY OF CALIFORNIA, SAN FRANCISCO · 2021 · $1,092,376

## Abstract

PROJECT SUMMARY/ABSTRACT
Dementia causes substantial burdens for patients, their caregivers, and health care systems. Recent and
potential changes in health care policy indicate a shift towards reimbursement models that could sustain
evidence-based dementia care. Currently, there is a wide gap between best practice in dementia and real-
world care delivery. Scalable, effective, and patient-centered dementia care models that are aligned with
trends in reimbursement reform are needed now. The Care Ecosystem is a dementia support program that
combines elements of effective programs into a scalable model that could be successful in the new policy
environment. Care is delivered via the phone and web by unlicensed Care Team Navigators, who are trained
and supervised by a nurse, social worker, and pharmacist. Proactive care modules focus on caregiver support
and education, medication consultation, support around medical, financial, and legal decisions, and behavior
management. We are evaluating the short-term impact of the Care Ecosystem on psychosocial and economic
outcomes in a randomized controlled trial, funded by the Centers for Medicare and Medicaid Innovation.
Patients and caregivers from rural and urban locales, with a range of socioeconomic characteristics, and
cohorts of Spanish and Cantonese speaking persons are included. Short-term (6 month) results suggest
benefit, and we expect that the greatest impact of our care program will be realized in the long term across all
stages of dementia. This proposed project would continue the care and measurement in our existing cohort to
determine the 5-year treatment effects and to characterize the patients and caregivers most likely to benefit. In
Aim 1, we will evaluate the Care Ecosystem's effects on patient quality of life, time to nursing home placement,
cost of care, and caregiver burden, depression, and health across the disease trajectory. In Aim 2, we will
determine the differential treatment effects by rural/urban locale, household income, ethnic minority status, and
by severity of behavioral symptoms, caregiver burden, and social isolation. In Aim 3, we will determine the
effects of Care Ecosystem on end of life care among patients who die. By clarifying the impacts of this scalable
dementia care program, our project would provide important guidance as health systems determine what
dementia care services to provide and to which beneficiaries. In addition, results would provide a framework for
caring for a diverse population of patients and caregivers across the care continuum.

## Key facts

- **NIH application ID:** 10158375
- **Project number:** 5R01AG056715-05
- **Recipient organization:** UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
- **Principal Investigator:** Katherine Laurel Possin
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2021
- **Award amount:** $1,092,376
- **Award type:** 5
- **Project period:** 2017-09-30 → 2023-05-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10158375

## Citation

> US National Institutes of Health, RePORTER application 10158375, The Care Ecosystem: Navigating patients and caregivers through stages of dementia care (5R01AG056715-05). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10158375. Licensed CC0.

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