Maximizing Independence at Home (MIND at Home®)
A comprehensive and scalable home-based dementia care navigation program for people living at home with cognitive impairment and their families.
What is the MIND at Home Program?
Alzheimer’s disease and related dementias are high prevalence, high cost, complex chronic conditions. Most persons living with dementia are being cared for at home and do not have access to dementia care management despite the availability of effective disease management strategies proven to improve outcomes and reduce health care costs.
MIND at Home® is comprehensive, family-centered care coordination program for community-living persons with dementia and cognitive impairment and their families that has been developed and tested by Johns Hopkins researchers and dementia specialists over the past 15 years. Delivered by an interdisciplinary team, the program systematically assesses and addresses a broad range of dementia-related care needs that place people at risk for premature and unwanted residential care placement, poor quality of life, health disparities, hospitalizations, and family caregivers at risk for burnout and other negative health impacts.
MIND at Home has been implemented across community organizations, health plans, health systems, home care, and primary care clinics with diverse locations, staffing and patient populations. Our experienced clinical and operational leadership team provides support to adopters, from program start-up and adaptation to maintenance. We adapt our program tools, assessments, and supporting materials to meet each organization’s unique setting, needs, and program goals.
What are the features of MIND at Home?
Supported by a full suite of program tools and training resources, MIND at Home uses a collaborative team-based care management approach to deliver family-centered dementia care coordination services. The program features:
- Detailed family-centered needs assessment that considers medical and non-medical needs of both the person and their caregiver (60-90 minute initial assessment; in-home or telephonic/virtual)
- Personalized care planning, with needs prioritized based on patient and care partner goals of care
- Implementation of care plan, care strategies, and caregiver supports by Memory Care Coordinator using standardized MIND at Home best practices- and need-based protocols and interdisciplinary team-based consultation
- Monitoring and revision of care plan over time
- Program graduation (when indicated)
Value proposition of MIND at Home
The overall goal of the program is to address dementia-related needs and challenges that help people stay well at home. Research and program evaluation results demonstrate the acceptability and feasibility of delivering the program in diverse community and practice settings, as well as benefits of enabling people living with dementia to stay at home longer, fewer unmet care needs, better quality of life, reduced acute health care utilization (e.g., Emergency Department visits, hospitalizations), and lower family care partner burden, at a lower cost of health care. The potential value proposition includes:
- Increase patient/member longevity in home/community
- Reduce unmet care needs/improve care quality
- Improve clinical and health related outcomes (fewer unmet needs, better quality of life)
- Reduce burden for care partners
- Better patient satisfaction metrics
- Increased utilization of respite care and appropriate LTSS utilization
- Reduced Medicaid and Medicare spend
- Reduce nursing home, acute care and emergency department (ED) utilization
- Increased ability for providers to practice at top of license
- Positioning for risk-sharing agreements or narrow networks