Building a Care Ecosystem
The Care Ecosystem model was designed to help address the unmet needs of persons with dementia and their caregivers.

What is the Care Ecosystem?

The Care Ecosystem is a model of dementia care designed to provide personalized, cost-efficient care for persons with dementia (PWD) and their caregivers. This telephone and web-based intervention was developed and studied across California, Nebraska and Iowa via an award from the Center for Medicare and Medicaid Innovation (CMMI grant number 1C1CMS331346) from 2014–2018 and continues to be studied with funding from the National Institute for Health (NIH/NIA grant number R01 AG056715) from 2017–2022.

The Care Ecosystem model includes:

  • Care team navigators (CTNs)
  • Clinicians with dementia expertise (nurse, pharmacist, social worker)
  • Care protocols

The CTN is the main point of contact for patients and caregivers in the Care Ecosystem. They are unlicensed yet trained to screen for dementia-related needs and provide support and information. Their work is guided by care protocols and they are supported and supervised by a clinician (nurse or social worker).

Who is the Care Ecosystem for?

The Care Ecosystem was designed to enable health systems and clinics to provide dementia-capable care to the growing population affected by dementia and their caregivers.

The Care Ecosystem Toolkit includes:

This toolkit provides an overview of the Care Ecosystem model and how to implement it in your institution.

Download the Toolkit

How Can the Care Ecosystem Toolkit be Used?

The Care Ecosystem Toolkit was developed using public funds and is available free of charge with attribution to the Regents of the University of California. This work is licensed under the Creative Commons Attribution 4.0 International License. To view a copy of this license, visit creativecommons.org/licenses/by/4.0 or send a letter to Creative Commons, PO Box 1866, Mountain View, CA 94042, USA.

For more information, please email Sarah.Dulaney@ucsf.edu.

Care Ecosystem Implementation Projects

Care Ecosystem Scientific Publications

  1. Possin KL, Merrilees JJ, Dulaney S, Bonasera SJ, Chiong W, Lee K, Hooper SM, Allen IE, Braley T, Bernstein A, Rosa TD, Harrison K, Begert-Hellings H, Kornak J, Kahn JG, Naasan G, Lanata S, Clark AM, Chodos A, Gearhart R, Ritchie C, Miller BL. Effect of Collaborative Dementia Care via Telephone and Internet on Quality of Life, Caregiver Well-being, and Health Care Use: The Care Ecosystem Randomized Clinical Trial. JAMA Intern Med. 2019. doi: 10.1001/jamainternmed.2019.4101.
  2. Bernstein A, Harrison KL, Dulaney S, Merrilees J, Bowhay A, Heunis J, Choi J, Feuer JE, Clark AM, Chiong W, Lee K, Braley TL, Bonasera SJ, Ritchie C, Dohan D, Miller BL, Possin KL. The Role of Care Navigators Working with People with Dementia and Their Caregivers. J Alzheimers Dis. 2019. doi: 10.3233/JAD-180957.
  3. Rosa TD, Possin KL, Bernstein A, Merrilees J, Dulaney S, Matuoka J, Lee KP, Chiong W, Bonasera SJ, Harrison KL, Kahn JG. Variations in Costs of a Collaborative Care Model for Dementia. J Am Geriatr Soc. 2019. doi: 10.1111/jgs.16076.
  4. Guterman EL, Allen IE, Josephson SA, Merrilees JJ, Dulaney S, Chiong W, Lee K, Bonasera SJ, Miller BL, Possin KL. Association Between Caregiver Depression and Emergency Department Use Among Patients With Dementia. JAMA Neurol. 2019. doi: 10.1001/jamaneurol.2019.1820.
  5. Chen Y, Wilson L, Kornak J, Dudley RA, Merrilees J, Bonasera SJ, Byrne CM, Lee K, Chiong W, Miller BL, Possin KL. The costs of dementia subtypes to California Medicare fee-for-service, 2015. Alzheimers Dement. 2019;15:899–906. doi: 10.1016/j.jalz.2019.03.015.
  6. Bernstein A, Rogers KM, Possin KL, Steele NZR, Ritchie CS, Miller BL, Rankin KP. Primary Care Provider Attitudes and Practices Evaluating and Managing Patients with Neurocognitive Disorders. J Gen Intern Med. 2019;34:1691–1692. doi: 10.1007/s11606-019-05013-7.
  7. Merrilees JJ, Bernstein A, Dulaney S, Heunis J, Walker R, Rah E, Choi J, Gawlas K, Carroll S, Ong P, Feuer J, Braley T, Clark AM, Lee K, Chiong W, Bonasera SJ, Miller BL, Possin KL. The Care Ecosystem: Promoting self-efficacy among dementia family caregivers. Dementia (London). 2018:1471301218814121. doi: 10.1177/1471301218814121.
  8. Possin KL, Merrilees J, Bonasera SJ, Bernstein A, Chiong W, Lee K, Wilson L, Hooper SM, Dulaney S, Braley T, Laohavanich S, Feuer JE, Clark AM, Schaffer MW, Schenk AK, Heunis J, Ong P, Cook KM, Bowhay AD, Gearhart R, Chodos A, Naasan G, Bindman AB, Dohan D, Ritchie C, Miller BL. Development of an adaptive, personalized, and scalable dementia care program: Early findings from the Care Ecosystem. PLoS Med. 2017;14:e1002260. doi: 10.1371/journal.pmed.1002260. PubMed Central PMCID: PMC5360211.