DEEP Care Management Model Designed for Patients and Their Caregivers

Department of Medicine geriatricians are teaming up with the Duke Population Health Management Office (PHMO) on a new longitudinal dementia care management model for patients and their caregivers.

Dementia Education and Engagement Program (DEEP) is an evolution of existing complex care management that was developed out of longstanding engagement between PHMO and geriatrics, which prompted an analysis of available data and deepening appreciation of the complex needs that have gone unaddressed for people living with dementia and their care partners.

DEEP is striving to engage programs that span multiple elements of the Duke Health system, bringing together PHMO care management, the Geriatrics Evaluation and Treatment Clinic, Duke Dementia Family Support Program, the Duke Caregiver Support Program, and primary care among others to interact more seamlessly in supporting patients. 

The core interprofessional team will include the expertise of nurse care managers, a geriatrics nurse practitioner, pharmacist, and an occupational therapist.  Once enrolled, the yearlong program will include a home visit  to fully assess and address the well-being of both the patient and the involved care partners, and longitudinal caregiver education and support for advanced care planning, safety, and connection to community resources.

“Putting the patient and care partner in the center of a robust team of professionals while keeping their relationship to this team streamlined through one nurse care manager over the course of a year will support established relationships in the Geriatrics Clinic and primary care,” said Heidi White, MD, vice chief for Clinical Affairs in the Geriatrics division.

During the long and variable course of dementia, patients living with this disease interact with many specialists in the Department of Medicine because of their other acute and chronic conditions. The DEEP team hopes that providing this type of patient and caregiver support will make these interactions more patient centered, and give everyone the framework including knowledge of what matters most to the patient and their care partner in order to develop realistic diagnostic and therapeutic planning to the individual needs of these patients. 

From a referring provider perspective, the DEEP program will be an important service to complement the medical care that Duke provides to this population, said Milta Little, DO, geriatric medicine specialist.  Patients and caregivers will have one point person to guide them towards the right education, resources, and support services to meet their needs now, as well as to help anticipate future needs.

“It is critical for people to receive the right support that meet their needs in between medical appointments, without having to do all their own research to find it,” Dr. Little said. “We hope that the combination of medical care and care management will help people stay in their homes longer, more independently, with their care goals actively known and met.”

The team also hope that the DEEP service will help catch early warning signs to prevent ED visits and hospitalizations.

“DEEP is a great example of holistic, person-centered care that the Department of Medicine strives to provide,” Dr. Little added.