“Self-care is already a challenge for dementia patients, and it is often made dramatically more complex by the presence of additional chronic conditions. By taking part in this program, we improve our ability to proactively manage patient health conditions in the home.”
Dr. Christopher Dennis
Chief Behavioral Health Officer, Landmark Health
A Specialized Care Management Program For High-Risk Members With Cognitive Impairment
Benefits for Plans
Benefits for Members with Cognitive Impairment
Improve Caregiver Self-Efficacy
The Ceresti Virtual Care Program teaches, empowers and supports family caregivers to be more proactive and effective in managing the care of a loved one (Member) with cognitive impairment.
We accomplish this by delivering personalized content to caregivers via secure technology that is accessible from anywhere, by anyone; and supporting caregivers with a dedicated remote Ceresti coach (e.g., social worker).
Reduce Potentially Preventable Hospitalizations for Members
We train and support family caregivers to detect the signs and symptoms of emerging health issues in the Member, and engage them in remote assessments (informed by predictive analytics) to monitor the Member’s health.
Ceresti coaches manage alerts via caregiver coaching, or by making referrals to care managers, a nurse hotline, providers; or by facilitating a telehealth visit.
Members with Cognitive Impairment Incur More than 50% of Total Hospitalizations
Members with cognitive impairment (e.g., dementia, stroke, Parkinson’s, traumatic brain injury and other conditions that prevents effective self-management) represent about 30% of total Medicare Advantage Member. These Members incur more than 50% of total health plan hospitalizations and an even higher percentage of potentially preventable hospitalizations. A condition like dementia, on its own, drives 25-30% of a health plan’s total hospitalizations.
The Dementia Cost Multiplier Illustrated via Utilization and Costs
The Ceresti Virtual Care Program engages these vulnerable and costly Members, through their family caregivers, to improve cost and quality outcomes for a difficult-to-engage population.
We use claims and other data sources to risk-stratify Members based on their likelihood of an emergency department visit or a hospitalization. We predict the most likely underlying causes (e.g., dehydration, hypertension, medication side effect) for such an acute event (e.g., fall, stroke, infection) and use this information to drive Member-specific risk assessments that are specifically aimed at identifying the early warning signs of issues that could lead to a preventable hospitalization. In parallel, we train the family caregiver to look for specific signs and symptoms in the Member, which may include asking the caregiver to report specific biometrics (e.g., blood pressure, weight, etc.).
The ability to secure multiple risk assessments every week about Members, via their caregivers, is enabled by high levels of caregiver engagement (45 minutes per week) that we achieve using a combination of education, support and remote coaching.
Out modular technology-based approach supports a variety of deployment options. Ceresti can manage the Virtual Care Program independently; or alternatively, we can support and train health plans and providers on how to integrate our technology and content into their existing care management capabilities.