Spotlight on Innovation: Dementia Care Coordination Program

We're highlighting the cutting-edge programs and successful strategies used by the 2018 recipients of n4a's Aging Innovation Awards in this weekly spotlight feature. This week we're focusing on the Jefferson Area Board for Aging (JABA), winner in the Health-LTSS Integration category.

During n4a's 2018 Annual Conference and Tradeshow, the top four highest-scoring Innovations winners won cash awards thanks to the generous support of AIA sponsor 
WellCare Health Plans. Naming JABA the fourth place winner, n4a presented the agency with a check for $500.

Recognizing the challenges that families face in navigating care options after a new diagnosis of dementia, JABA partnered with the Virginia Department for Aging and Rehabilitative Services and the University of Virginia's Memory and Aging Care Clinic in 2015 to apply for a grant from the Administration for Community Living (ACL) that would allow them to develop best practices for dementia care coordination for the state of Virginia. The partnership was driven by Goal Four of the 2015-2019 Virginia Dementia State Plan: to provide access to quality coordinated care for individuals with dementia in the most integrated setting.

The Dementia Care Coordination Program is an innovative integrated and coordinated care system for individuals living with dementia, their families and caregivers. Through the three-year pilot program, Care Coordinators with backgrounds in health, social work and aging underwent a specialized 30-hour training before working intensively with caseloads of 50 families each. Care Coordinators provided long-term coordinated care, including options counseling, education on dementia, behavioral symptom management training and eligibility assistance.

Another goal of the pilot was to develop a replicable best practice for care coordination for individuals with dementia and their caregivers. Outcomes were measured by a 20-item satisfaction survey completed by individuals and primary caregivers. In addition, care coordination participants were asked to complete measures of hospital utilization, depression, behavior and neurological symptoms, functioning and quality of life when they join the program and at annual follow-up appointments.

An analysis of these outcomes and lessons learned will be used to develop a replication manual that will be publicly available from ACL and the Virginia Department for Aging and Rehabilitative Services. This manual will examine all aspects of the program, including recommended staff trainings, a pro-forma budget, the program structure and goals, the Care Coordination Guide that is provided to individuals and all other related materials.

Though the pilot program concludes this month, the Memory and Aging Care Clinic has already received another grant to continue providing care coordination to individuals living with dementia and their caregivers.

To learn more about this year's winners, read our press release and check out our book of winners to learn how your agency can implement this or similar programs in your community!



USAging Fact: Learn about your peers’ work—and how it can fit into your agency’s goals! The AIA Awards recognizes successful and innovative programs that USAging members have developed to serve older adults. Get inspiration from our 2023 winners!