Reducing the Cost and Risk of Dementia

Global Challenge & CMS Strategy

• The global prevalence of dementia is described as "overwhelming," with no cure currently available, necessitating a shift toward risk reduction, prevention, and better management of existing cases.
• CMS is leveraging payment rules and billing codes to incentivize clinicians to conduct cognitive impairment screenings and provide standardized assessments during preventive visits.
• Sherry Ling (CMS) emphasized that while payment reform is necessary, it is not sufficient; sustainable solutions require engaging individuals in their own health management outside clinical settings.
• CMS is piloting the "Emergency Triage, Treat, and Transport" (ET3) model to allow paramedics to transport dementia patients to preferred locations or manage care on-site rather than automatically routing them to the nearest emergency department.
• Evidence suggests that early detection through annual wellness visits can identify warning signs like financial mismanagement or medication errors, though consistent uptake varies across the country.

Workforce & Emergency Department Innovations

• Geriatric Emergency Departments (GEDs) have expanded from 8 accredited facilities in May 2022 to 105 within 18 months, utilizing a three-level accreditation system (Level 1 being the highest).
• Approximately 90% of GEDs are able to sustain operations without major funding beyond initial philanthropic seed support.
• GEDs feature specialized environments (e.g., calm lighting, separate entrances, assistive audio technology) and trained staff to reduce trauma and confusion for patients with cognitive loss.
• Data indicates that GED patients experience lower hospitalization rates, fewer falls within a month of discharge, and higher satisfaction compared to standard EDs.
• A pilot in San Francisco aims to create a regional network of GEDs to mitigate patient diversion issues when single hospitals are saturated.
• Jenny Chin Hansen highlighted a systemic disincentive where geriatricians often earn less than primary care physicians despite higher specialization, contributing to workforce shortages.

The Financial Sector's Role

• Bank of America serves one out of every two U.S. households, positioning the firm to address the 40 million caregivers in the country and the financial impacts of cognitive decline.
• Research reveals a disconnect where 88% of employers claim to offer caregiving benefits, yet fewer than 30% of employees are aware of them.
• Financial stress impacts retirement savings, with women holding a median of $30,000 compared to $100,000 for men, largely due to caregiving responsibilities forcing workforce interruptions.
• Bank of America has accredited 2,000 financial advisors in "longevity" to better assist clients with life-stage financial planning and early detection of financial mismanagement indicative of cognitive decline.
• The bank employs a gerontologist on staff to assist employees in navigating complex family financial and legal matters, such as establishing powers of attorney.
• Early signs of cognitive decline often manifest as an inability to manage daily finances, a trend observed by financial advisors and caregivers alike.

Home Care & Community Engagement

• Home Instead provides over 80 million hours of care annually, with roughly two-thirds of clients having Alzheimer's or dementia, operating in 90,000 homes across 12 countries.
• The organization's "person-centered" training model emphasizes knowing the patient's life history (e.g., career, passions) to personalize care tactics, which has been validated by the Queen's Award for Innovation.
• Evidence shows that clients receiving specialized home care have fewer doctor visits, lower emergency room admissions, shorter hospital stays, and lower readmission rates.
• Home Instead offers free training resources to the public via caregiverstress.com and helpforalzheimersfamilies.com, including the "Confidence to Care" book and mobile app.
• The "I'm Ready to Care" initiative texts weekly care missions (e.g., "Say hello to a senior") to activate community volunteers and combat social isolation.
• The "Champions of Aging" pilot program recruits college graduates and gap-year students for immersive service years to build a future workforce for the aging sector.

Patient Advocacy & Early Diagnosis

• Michael Belleville, diagnosed with Lewy body dementia at 52, criticized the initial diagnosis process for lacking referrals, care plans, or support, leaving families to rely on "Dr. Google."
• Belleville advocates for mandatory cognitive screening starting at ages 30 or 40 to establish baselines, similar to cancer screenings, to enable early intervention.
• Patients emphasize that an early diagnosis provides the critical opportunity to "get busy living," allowing individuals to make life decisions regarding their future trajectory before full progression.
• The "nothing about us without us" principle is central to developing dementia-friendly communities and ensuring lived experiences drive policy.
• Stigma and fear of diagnosis remain significant barriers to screening, requiring a shift from treating dementia as a terminal event to a manageable life stage.

Research & Systemic Barriers

• Current research protocols often require a caregiver to accompany a patient with dementia, creating a logistical barrier for individuals without available support.
• Financial services data (e.g., repeated $500 withdrawals) can serve as early indicators of cognitive decline, but ethical and privacy frameworks for acting on this data need development.
• Jill Lesser noted that 90% of dementia diagnoses in the U.S. currently occur at a stage analogous to stage four cancer, highlighting a failure in prevention and early detection.
• CMS is exploring alternative payment models that measure outcomes beyond hospitalization, aiming to align care with patient-defined goals rather than just episodic medical treatments.
• Employers are increasingly recognizing caregiving as a productivity and cost issue, prompting the development of robust, visible benefits like legal support and caregiver networks.
• The transition from fee-for-service to value-based care is hindered by a lack of evidence linking screening to improved long-term management outcomes, though pilot programs show promise.