Aging Brain Care Virtual Program

The program involves a virtual intervention to be delivered by RN or SW care coordinators over one year. Every care partner will receive monthly virtual visits during the first 3 months and then quarterly or more depending on assessed need. The intervention relies on a tailored approach in which patient and caregiver needs are identified during visits using validated assessment tools and addressed with standardized protocols. Protocols include management of behavioral/psychological symptoms of dementia, caregiver stress, medication management, comorbidity management and advance care planning.

Patient Inclusion Criteria: * 65 and older, * active primary care patient (visit in past 14 months), * diagnosis of Alzheimer's disease and related dementias (ADRD) based on ICD criteria in primary care problems list. Patient Exclusion Criteria: * enrolled in hospice at the study start (study screening)or * living in a long term care nursing facility. Care Partners Inclusion Criteria: * 18 and older, * able to access a phone or computer for intervention delivery in English, and * identified in the EMR as the emergency contact or as the primary care partner. Care Partners Exclusion Criteria: \- Individuals who decline to participate in the ABCV intervention