Project Summary

This research project is in progress. PCORI will post the research findings on this page within 90 days after the results are final.

What is the research about?

Living with dementia, depression, or delirium can be hard for patients and their families. These families may need help managing care from many doctors, tracking medicines, dealing with problem behaviors, and finding community resources. Family members may feel alone or depressed.

Home-based or telephone-based care can help patients and families manage these issues. This study is looking at whether either method helps prevent hospital stays and emergency room, or ER, visits for patients with dementia, depression, or delirium. The study focuses on older adults who receive insurance from a Medicare Advantage plan.

Who can this research help?

Findings from the study can help doctors and Medicare Advantage plan managers decide how to improve health care for older adults living with dementia, depression, or delirium.

What is the research team doing?

The researchers are enrolling 576 Medicare Advantage plan members aged 65 and older with dementia, depression, or delirium. Patients live at home or in assisted living in Connecticut. Patients receive, by chance, either home-based or telephone-based care management currently available to Medicare Advantage plan members.

Patients in the home-based care group receive four home visits over three to four months. They also have monthly phone calls for eight months. Home-based care is led by a nurse practitioner with experience working with older people with mental health issues and includes visits from a team of healthcare workers. The team tracks patients’ mental status and depression and reviews their medicines. The services they offer can include physical therapy, occupational therapy to teach patients how to do everyday activities at home, nutrition advice, and social support services. Team members also coach patients and their caregivers on how to cope with stressful experiences.

Patients who get telephone-based care management receive phone calls from nurses who manage their care. These patients may also have in-home visits from a nurse or social worker, depending on the patients’ needs.

The researchers are tracking whether patients have hospital stays or ER visits. They speak with patients and their family caregivers at the start of the study and after 6 and 12 months. Patients give information about their mood, difficulty doing everyday activities, and quality of life. The research team is also collecting information about issues important to patients that come up during these conversations. Caregivers talk about the amount of care they are providing; their well-being; and the emotional, physical, social, and financial effects of caregiving.

The research team is meeting separately with the home-based and telephone-based care team members. They are reviewing how well each approach works to help older patients living with dementia, depression, or delirium stay at home, and to help their families learn how to manage these health problems. The team is also speaking with Medicare Advantage plan managers. These discussions are helping the team understand how the plan managers decide which care management approach to offer. An advisory committee that includes patients and families is giving input during the study.

Research methods at a glance

Design Elements Description
Design Randomized controlled trial
Population Adults aged 65 and older who have dementia, depression, or delirium, live at home or in an assisted living facility in Connecticut, and are enrolled in a Medicare Advantage plan
  • Home-based care management
  • Telephone-based care management

Primary: hospitalization or use of ER without hospitalization

Secondary: depression rating scale for patients, family member’s report on the level of assistance required to care for patient, family member’s self-reported well-being, patient-reported degree of difficulty doing physical activities, patient-reported quality of life for patients with dementia, family member’s report of patient’s psychiatric symptoms, depression rating scale for family members, burden of caregiving scale for family members

Timeframe 12-month follow-up for primary outcome

Project Information

Richard Fortinsky, PhD
University of Connecticut School of Medicine
3D Team Care for Cognitively Vulnerable Older Adults

Key Dates

September 2015
January 2026

Study Registration Information


Award Type
Health Conditions Health Conditions These are the broad terms we use to categorize our funded research studies; specific diseases or conditions are included within the appropriate larger category. Note: not all of our funded projects focus on a single disease or condition; some touch on multiple diseases or conditions, research methods, or broader health system interventions. Such projects won’t be listed by a primary disease/condition and so won’t appear if you use this filter tool to find them. View Glossary
Populations Populations PCORI is interested in research that seeks to better understand how different clinical and health system options work for different people. These populations are frequently studied in our portfolio or identified as being of interest by our stakeholders. View Glossary
Intervention Strategy Intervention Strategies PCORI funds comparative clinical effectiveness research (CER) studies that compare two or more options or approaches to health care, or that compare different ways of delivering or receiving care. View Glossary
State State The state where the project originates, or where the primary institution or organization is located. View Glossary
Last updated: October 18, 2023