Community living (no nursing home placement) persons with a diagnoses of dementia will be recruited. They must also have a caregiver (family member or friend) who speaks English or Spanish and is not cognitively impaired. They will be randomized into one of three arms: 

  • Health systems-based dementia care (based on the UCLA Alzheimer’s and Dementia Care program) provided by a nurse practitioner or physician’s assistant Dementia Care Specialist who works within the Wake Forest health system. 
  • Community-based dementia care (using the BRI Benjamin Rose Institute Care Consultation model) provided by a social worker or nurse Care Consultant who works at Forsyth County Senior Services or Senior Resources of Guilford County. 
  • Both arms include structured assessments and creation of care or action plans, care coordination, and caregiver education and support, but they differ in key areas including the frequency and mode of communication with persons with dementia and caregivers, the degree of integration into the health system, including order-writing capability and


Primary outcomes

  •  NPI-Q Severity (patient behaviors) 
  • Caregiver strain (MCSI) 

Secondary Outcomes

  •  NPI-Q Distress (caregiver) 
  • Caregiver depression (PHQ-9) 
  • Caregiver self-efficacy 

Tertiary Outcomes 

  • Cognition 
  • Functional status 
  • Goal attainment 
  • Mortality
  • Time spent at home
  • Inpatient hospital use*
  • Acute inpatient rehabilitation use*
  • Post-acute SNF use*
  • Hospice use*
  • Long-term nursing home use*
  • Quality of dementia care
  • Caregiver satisfaction with dementia care
  • Dementia Burden Scale-Caregiver
  • Clinical Benefit
  • Quality of Life in Alzheimer’s Disease
  • Spouse caregiver utilization
  • Cost-effectiveness analysis
  • Patient Quality of life 

Learn more about Dementia and Cognitive Impairment research results from pcori.