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The Aging Brain Care (ABC) program addresses dementia and its sustainability and scalability through comprehensive assessment, severity diagnosis, caregiver burden evaluation, and biopsychosocial needs planning. A personalized care plan includes deprescribing inappropriate medications and co-managing comorbidities with primary care. In federally qualified health centers, ABC reduces dementia-related behavioral symptoms, caregiver burden, and inappropriate medication use, while supporting care transitions and community resource access for vulnerable dyads.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/comprehensive-dementia-care-to-address-multimorbidity-across-inpatient-residential-and-community-settings-issue-247-abstract-citation-id-igaf122830/422025/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/comprehensive-dementia-care-to-address-multimorbidity-across-inpatient-residential-and-community-settings-issue-247-abstract-citation-id-igaf122830/422025.png","ImageObject",300,407,{"name":92,"@type":93},"Grenda","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-09-28",true,{"@type":102,"interactionType":103,"userInteractionCount":52},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What core steps does the ABC program use to address comorbidities in dementia care?","Question",{"text":112,"@type":113},"ABC conducts comprehensive assessment to diagnose dementia and its severity, reviews comorbid medical conditions, evaluates caregiver burden, and determines dyads’ biopsychosocial needs and goals. It then co-develops a personalized care plan with deprescribing and collaborative co-management with primary care.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What improvements did the ABC program achieve in the clinical trial setting?",{"text":117,"@type":113},"In federally qualified health centers, ABC reduced dementia-related behavioral and psychological symptoms, lowered informal caregiver burden, and decreased the use of inappropriate medications.",{"name":119,"@type":110,"acceptedAnswer":120},"How does ABC support care beyond the clinic across home, hospital, and community settings?",{"text":121,"@type":113},"ABC facilitates care transition from home to hospital and subacute rehabilitation and back home, partners with community-based organizations to connect families to home and community resources, and uses trained community health workers to deliver care consistent with patient and family preferences.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},422025,1790767911,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":52,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":8,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":81,"preview_page_count":4},7971474921005,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Innovation in Aging, 2025, Vol. 9, No. S2 247  \nAbstract citation ID: igaf122.830  \nCOMPREHENSIVE DEMENTIA CARE TO ADDRESS MULTIMORBIDITY ACROSS INPATIENT,  \nRESIDENTIAL AND COMMUNITY SETTINGS  \nMalaz Boustani, Indiana University, Indianapolis, Indiana, United States  \nFully addressing dementia requires attention to patients at risk for dementia. The Aging Brain Care (ABC) program has been addressing this along with its sustainability and scalability over the past 17 years. The ABC populations disproportionately suffer from dementia, comorbid medical conditions, and high social frailty. To address comorbidities, the ABC program conducts a comprehensive assessment to diagnose dementia and its severity, reviews medical conditions, assesses the burden on informal caregivers, determines the biopsychosocial needs of the dyads, and identify their goals and preferences. Then it co-develops a personalized care plan including de-prescribing inappropriate medications and doing co management of comorbid conditions in collaboration with primary care. In a clinical trial, conducted in Federally Qualified Health Centers, the ABC program reduced the behavioral and psychological symptoms related to dementia, the burden of informal caregivers, and the use of inappropriate medications. To enhance the ABC program’s work with vulnerable populations, it facilitates care transition from home to hospital and subacute rehabilitation and back to home. ABC also partners with community-based organizations to identify home and community-based resources to overcome care needs and address social determinants of health. Community health workers trained and supported to deliver care across settings in accordance with the patients’ and family preference have provided care to an average 400 dyads per year. Work is now underway to expand the care navigation roles to address conditions other than dementia, and to support the diagnostic process for patients at risk for dementia.","cbCaivLoPXD96Dgb","https://ap.wps.com/l/cbCaivLoPXD96Dgb","pdf",270891,"English","# Overview of the ABC program\n## Comprehensive assessment and care planning\n## Clinical trial outcomes\n## Care transitions and community partnerships\n## Expansion and future work","[{\"question\":\"What core steps does the ABC program use to address comorbidities in dementia care?\",\"answer\":\"ABC conducts comprehensive assessment to diagnose dementia and its severity, reviews comorbid medical conditions, evaluates caregiver burden, and determines dyads’ biopsychosocial needs and goals. It then co-develops a personalized care plan with deprescribing and collaborative co-management with primary care.\"},{\"question\":\"What improvements did the ABC program achieve in the clinical trial setting?\",\"answer\":\"In federally qualified health centers, ABC reduced dementia-related behavioral and psychological symptoms, lowered informal caregiver burden, and decreased the use of inappropriate medications.\"},{\"question\":\"How does ABC support care beyond the clinic across home, hospital, and community settings?\",\"answer\":\"ABC facilitates care transition from home to hospital and subacute rehabilitation and back home, partners with community-based organizations to connect families to home and community resources, and uses trained community health workers to deliver care consistent with patient and family preferences.\"}]","COMPREHENSIVE DEMENTIA CARE TO ADDRESS MULTIMORBIDITY ACROSS INPATIENT, RESIDENTIAL AND COMMUNITY SETTINGS - Issue 247 - Abstract citation ID igaf122.830 | PDF",1790626059]