DOI: 10.1002/alz.075130 ISSN: 1552-5260

A Collaborative Care Coordination Model: Reaching older adults living alone with cognitive impairment.

Carol A Manning, Shannon Reilly, Samantha Fields, Elizabeth Boyd
  • Psychiatry and Mental health
  • Cellular and Molecular Neuroscience
  • Geriatrics and Gerontology
  • Neurology (clinical)
  • Developmental Neuroscience
  • Health Policy
  • Epidemiology



The number of persons aged 65+ with Alzheimer’s Disease who live alone in Virginia was estimated at 42,000 in 2018. This population commonly has need for therapeutic, social, and other services, however, therapists and social and other service providers commonly lack knowledge of how to reach this population. We sought to identify people with dementia who live alone in Virginia, and to provide services that would be beneficial for psychological health.


We conducted multifaceted outreach and delivered two programs for people with dementia living alone, (1) individualized care coordination provided by a Dementia Care Manager that focuses on behavioral symptom management training and education, (n = 51) and (2) the Effective Strategies Program (ESP) which includes education and support in memory, practical strategies, exercise, diet, home, and safety (n = 11). We assessed outcomes on depression using the Center for Epidemiologic Studies Depression Scale‐Revised and on behavioral symptoms using the Revised Memory and Behavior Problem Checklist & Neuropsychiatric Inventory‐Questionnaire in the Care Coordination participants.


At 12‐month follow‐up in the Care Coordination Program, depression significantly decreased and behavioral symptoms were significantly lower. Almost all (94%) of the participants reported overall the program in which they participated was beneficial.


Despite numerous challenges with reaching this population, gaining trust, and maintaining contact, it is possible to reach and provide beneficial services for people with dementia who live alone. Successes partnering with pre‐existing resources and recommendations for sustainability are highlighted.

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