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. 2022 Nov 29;21(2):281–325. doi: 10.11124/JBIES-22-00024
Author, year Title Type of source/study design (where applicable) Geographic location Setting Delivery format Population/condition Team composition Navigator title
Amjad et al.,32 2018 Health services utilization in older adults with dementia receiving care coordination: the MIND at Home trial Randomized controlled trial Baltimore, Maryland, US Home and community Phone and in person 70 years and older, English-speaking, community residing in northwest Baltimore (28 postal codes), with a reliable study partner (ie, dyad); met Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) criteria for dementia or cognitive disorder not otherwise specified, and had one or more unmet care needs on the Johns Hopkins Dementia Care Needs Assessment Interdisciplinary team of nonclinical memory care coordinators linked to a registered nurse and a geriatric psychiatrist Care coordinator
Bass et al.,59 2003 The Cleveland Alzheimer’s managed care demonstration: outcomes after 12 months of implementation Randomized controlled trial Cleveland, Ohio, US Home and community Phone People with memory problems and people with dementia (pre-diagnosis); 55 years and older; living in the community Lay team of care consultants and trained volunteers Care consultant
Bass et al.,45 2013 Caregiver outcomes of Partners in Dementia Care: effect of a care coordination program for veterans with dementia and their family members and friends Quasi-experimental study (participants were not randomized to intervention or control) US (Boston, Massachusetts; Providence, Rhode Island; Houston, Texas; Oklahoma City, Oklahoma; and Beaumont, Texas) Home and community (based out of a Veterans Affairs center) Phone, email, and mail Veterans with dementia (aged 50 years and older) and their caregivers Interdisciplinary team of care coordinators from Veterans Affairs and Alzheimer’s Association Care coordinator
Bass et al.,46 2014 A controlled trial of Partners in Dementia Care: veteran outcomes after six and twelve months Randomized controlled trial 5 regions in the US Home and community (based out of a Veterans Affairs center) Phone, email, mail, and in person Veterans with dementia and their caregivers Interdisciplinary team of care coordinators from Veterans Affairs and Alzheimer’s Association with administrative support Care coordinator
Bass et al.,47 2015 Impact of the care coordination program “Partners in Dementia Care” on veterans’ hospital admissions and emergency department visits Randomized controlled trial US (Boston, Massachusetts; Providence, Rhode Island; Houston, Texas; Oklahoma City, Oklahoma; and Beaumont, Texas) Home and community Phone, email, and mail Veterans with dementia and their caregivers Interdisciplinary team of care coordinators from Veterans Affairs and Alzheimer’s Association Care coordinator
Bernstein et al.,22 2019 The role of care navigators working with people with dementia and their caregivers Qualitative exploratory study California, Nebraska, and Iowa, US Home and community Phone and web-based Dyads made up of people with dementia and their caregivers; with a diagnosis, speaking English, Spanish, or Cantonese Interdisciplinary team of care team navigators, advanced practice clinical nurse, a social worker, and a pharmacist Care team navigator
Bernstein et al.,39 2020 Using care navigation to address caregiver burden in dementia: a qualitative case study analysis Qualitative exploratory study California and Nebraska, US Home and community (based out of urban academic health centers) Phone and web-based Dyads made up of people with dementia and their caregivers; with a diagnosis, speaking English, Spanish, or Cantonese Interdisciplinary team of care team navigators, advanced practice clinical nurse, a social worker, and a pharmacist Care team navigator
Chen et al.,55 2020 Effect of care coordination on patients with Alzheimer disease and their caregivers Quasi-experimental study Greenville, South Carolina, US N/A N/A People with dementia and their caregivers Interdisciplinary team included care coordinator and licensed social worker Care coordinator
Dang et al.,57 2008 Care coordination assisted by technology for multiethnic caregivers of persons with dementia: a pilot clinical demonstration project on caregiver burden and depression Qualitative study Miami, Florida, US Home and community Phone Home-dwelling veterans over the age of 60 years, with a diagnosis of dementia or related disorders; caregivers were required to live with the veteran Interdisciplinary team of nurse care coordinator and a support person, who also communicated with the care recipients’ providers Care coordinator
Dementia Waikato,66 2017 Dementia navigator service Brochure Waikato, New Zealand Home and community Phone and in person People with dementia and caregivers, residing in the Waikato District Health Board area, dementia diagnosis required, must be eligible for public health services Interdisciplinary team of registered nurses, occupational therapists, social workers, and dementia navigator Support coordinator
Department of Veterans Affairs,67 2020 Rural Interdisciplinary Team Training (RITT) dementia care coordinator program Information sheet US Home and community Phone and email Caregivers of veterans with dementia Interdisciplinary team of licensed clinical social workers and volunteers Dementia care coordinator
Fæø et al.,53 2020 The compound role of a coordinator for home-dwelling persons with dementia and their informal caregivers: qualitative study Qualitative study Norway Home and community Phone and in person Dyads made up of people with dementia and their care partners, who lived at home Clinical team of 2 specialist nurses acting as coordinators Coordinator
Fortinsky et al.,65 2002 Helping family caregivers by linking primary care physicians with community-based dementia care services: the Alzheimer’s Service Coordination Program Mixed methods Cleveland, Ohio, US Home and community Phone and in person People with dementia and their caregivers N/A Service coordinator
Galik and Stefanacci,69 2019 Improving care for patients with dementia: what to do before, during, and after a transition Editorial US Home and community N/A People with dementia and their caregivers Interdisciplinary team Alzheimer’s patient navigation
Galvin et al.,56 2014 Public–private partnerships improve health outcomes in individuals with early-stage Alzheimer’s disease Cross-sectional, non-randomized research study Missouri, US Home and community Phone and in person People with dementia and their caregivers, diagnosis required Interdisciplinary team of New York University researchers, the Missouri Department of Health and Senior Services, Area Agencies on Aging, and local Alzheimer’s Association Chapters Project Learn MORE (Missouri Outreach and Referral Expanded) coordinator
Goeman et al.,63 2016 Development of a model of dementia support and pathway for culturally and linguistically diverse communities using co-creation and participatory action research Qualitative study using a co-creation and participatory action research approach Australia Home and community Phone and in person Culturally and linguistically diverse community members with cognitive impairment living in the community and their family or caregiver Clinical team of nurses Specialist dementia nurse
Husebo et al.,54 2020 LIVE@Home.Path—innovating the clinical pathway for home-dwelling people with dementia and their caregivers: study protocol for a mixed methods, stepped-wedge, randomized controlled trial Study protocol 3 municipalities in Norway Home and community Phone and in person Dyads made up of people with dementia and their care partners, who lived at home Clinical team of 2 specialist nurses, acting as coordinators Coordinator
Joels and van Pol,51 2014 How to manage follow-up patients: Dementia Navigators Report/presentation slides Islington borough of London, UK Home and community Phone and in person People with dementia and their informal caregivers Interdisciplinary team of a full-time team leader with clinical and managerial responsibilities and 3 dementia navigators Dementia navigator
Judge et al.,48 2011 Partners in Dementia Care: a care coordination intervention for individuals with dementia and their family caregivers Qualitative descriptive analysis Huston, Texas and Boston, Massachusetts, US Home and community Phone Veterans with dementia and their primary caregivers Interdisciplinary team included the VA Dementia Care Coordinator who worked in the Veterans Affairs, and the Alzheimer’s Association Care Consultant who worked in the Alzheimer’s Association chapter Care coordinator
Lee et al.,61 2014 Integrating community services into primary care: improving the quality of dementia care Qualitative exploratory study Ontario, Canada Community (based out of primary care clinic) In person People with mild cognitive impairment or dementia and their caregivers Interdisciplinary team included a physician, nurse practitioner, registered nurse, social worker, occupational therapist, and pharmacist Clinic coordinator
Liu et al.,68 2019 Patient and caregiver outcomes and experiences with team-based memory care: a mixed methods study Mixed methods Southeastern US Community (based out of memory clinic) Phone and in person People with dementia and other memory issues and their caregivers Interdisciplinary team made up of a geriatric physician, nurse, nurse practitioner, and social worker who functioned as the dementia navigator Dementia navigator
McAiney et al.,60 2012 ‘Throwing a lifeline’: the role of First Link™ in enhancing support for individuals with dementia and their caregivers Mixed methods Ontario and Saskatchewan, Canada Home and community Phone People with dementia and their caregiver Lay team made up of First Link Coordinator who worked with Alzheimer Society and the family First Link coordinator
Merrilees et al.,40 2020 The Care Ecosystem: promoting self-efficacy among dementia family caregivers Qualitative exploratory study California, Nebraska, and Iowa, US Home and community Phone, email, mail, and in person Dyads made up of people with dementia and caregivers Interdisciplinary team made up of care team navigators, advanced practice nurse, social worker, and pharmacist Care team navigator
Morgan et al.,49 2015 A break-even analysis for dementia care collaboration: Partners in Dementia Care Cost analysis US Home and community Phone and email Veterans with dementia and their caregivers Interdisciplinary team made up of Veterans Health Administration Coordinator and Alzheimer’s Association coordinator Alzheimer’s Association care coordinator
Morgan et al.,50 2019 Does care consultation affect use of VHA versus non-VHA care? Cross-sectional research study 5 regions in the US Home and community Phone Veterans with dementia and their primary caregivers Interdisciplinary team made up of half-time Veterans Health Administration dementia care coordinator and a half-time Alzheimer’s Association care consultant Alzheimer’s Association care coordinator
Possin et al.,41 2017 Development of an adaptive, personalized, and scalable dementia care program: early findings from the Care Ecosystem Pragmatic randomized controlled trial US Home and community Phone, email, and in person People diagnosed with dementia of any type by any medical provider; 45 years and older; Medicare- or Medicaid-enrolled or pending; residing in California, Nebraska, or Iowa; a caregiver who may or may not reside with the patient; and fluency in English, Spanish, or Cantonese Interdisciplinary team made up of care team navigators, dementia specialist nurse, social worker, and pharmacist Care team navigator
Possin et al.,42 2019 Effect of collaborative dementia care via telephone and internet on quality of life, caregiver well-being, and health care use: the Care Ecosystem randomized clinical trial Randomized controlled trial California, Nebraska, and Iowa, US Home and community (based out of urban academic health centers) Phone, email, and mail Dyads made up of people with dementia and their caregiver; diagnosis required; speaking either English, Spanish, or Cantonese, residing in Iowa, California, or Nebraska Interdisciplinary team consisting of a care team navigator, advanced practice nurse, social worker, and pharmacist Care team navigators
Rosa et al.,43 2019 Variations in costs of a collaborative care model for dementia Cost analysis California, Nebraska, and Iowa, US Home and community (based out of urban academic health centers) Phone, email, and in person Dyads of persons with dementia and their caregiver; diagnosis required; speaking either English, Spanish, or Cantonese, residing in Iowa, California, or Nebraska Interdisciplinary team consisting of a care team navigator, advanced practice clinical nurse, social worker, and pharmacist Care team navigators
Samus et al.,33 2014 A multidimensional home-based care coordination intervention for elders with memory disorders: the Maximizing Independence at Home (MIND) pilot randomized trial Randomized controlled trial Baltimore, Maryland, US Home and community Phone, email, and in person People with cognitive disorder, 70 years and older, English-speaking, living in the community, had a reliable study partner (dyad) Interdisciplinary team made up of community workers (coordinators), registered nurse, and geriatric psychiatrist Memory care coordinator
Samus et al.,34 2015 A multipronged, adaptive approach for the recruitment of diverse community-residing elders with memory impairment: The MIND at Home experience Descriptive analysis Baltimore, Maryland, US Home and community Phone and in person Community-residing people in northwest Baltimore (28 postal codes), 70 years and older, English-speaking, met criteria for dementia or cognitive disorder, and had a reliable study partner (dyad) Interdisciplinary team made up of trained nonclinical community workers (ie, memory care coordinator), nurses, physicians (ie, geriatric psychiatrists), and occupational therapists Memory care coordinator
Samus et al.,35 2017 Comprehensive home-based care coordination for vulnerable elders with dementia: Maximizing Independence at Home-Plus—study protocol Protocol for randomized controlled trial US Home and community Phone and in person People with dementia and their caregivers Interdisciplinary made up of geriatric psychiatrist, registered nurse, occupational therapist, memory care coordinator Memory care coordinator
Samus et al.,36 2018 MIND at Home-streamlined: study protocol for a randomized trial of home-based care coordination for persons with dementia and their caregivers Protocol for randomized controlled trial Baltimore, Maryland, US Home and community Phone and in person Community-residing people in northwest Baltimore (28 postal codes), 70 years and older, English-speaking, met criteria for dementia or cognitive disorder, and had a reliable study partner (dyad) Interdisciplinary team made up of geriatric psychiatrist, registered nurse, occupational therapist, memory care coordinator Memory care coordinator
Silverstein et al.,58 2015 The Alzheimer’s Association Dementia Care Coordination program: a process evaluation, executive summary Mixed methods Massachusetts and New Hampshire, US Community In person People with dementia and their families N/A Care consultant
Tanner et al.,37 2015 A randomized controlled trial of a community-based dementia care coordination intervention: effects of MIND at Home on caregiver outcome Randomized controlled trial Baltimore, Maryland, US Home and community Phone and in person Community-residing people in northwest Baltimore (28 postal codes), 70 years and older, English-speaking, met criteria for dementia or cognitive disorder, and had a reliable study partner (dyad) Interdisciplinary team made up of geriatric psychiatrist, registered nurse, occupational therapist, memory care coordinator Memory care coordinator
Taylor et al.,62 2015 The Primary Care Navigator programme for dementia: benefits of alternative working models Report using qualitative assessment Gateshead and Halton, UK Community (based out of a general practitioner practice and a well-being enterprises community interest company) Phone and in person People with dementia, pre- and post-diagnosis Clinical; each site organized differently. At Gateshead, 2 people shared the primary care navigator role, switching roles as health care assistant and primary care navigator weekly. They worked with a clinical team, which included doctors, a registrar, nurse practitioners, and a nursing team. At Halton, 10 community well-being officers acted as primary care navigators. They had clinical backgrounds. They partnered with 17 practices. Primary care navigator
Tjia,44 2019 A telephone-based dementia care management intervention-finding the time to listen Editorial/ invited commentary California, Nebraska, and Iowa, US Home and community (based out of urban academic health centers) Phone and email Dyads made up of people with dementia and their caregivers; diagnosis required, speaking English, Spanish or Cantonese, and residing in Iowa, California, or Nebraska Interdisciplinary team made up of a care team navigator, dementia specialist nurse, social worker, and pharmacist Care team navigators
Willink et al.,38 2020 Cost-effective care coordination for people with dementia at home Prospective, quasi-experimental intervention trial design Baltimore and Maryland suburban District of Columbia, US Home and community Phone and in person Community-residing people in northwest Baltimore (28 postal codes), 70 years and older, English-speaking, met criteria for dementia or cognitive disorder, and had a reliable study partner (dyad) Interdisciplinary team made up of geriatric psychiatrist, registered nurse, occupational therapist, memory care coordinator Memory care coordinator
Wood et al.,52 2017 A holistic service for everyone with a dementia diagnosis (innovative practice) Report Islington borough of London, UK Home and community Phone, mail, and in person People with dementia and their caregivers Interdisciplinary team made up of dementia navigators, 3 full-time assistant practitioners, and specialist practitioner as team leader Dementia navigators
Xiao et al.,64 2016 The effect of a personalized dementia care intervention for caregivers from Australian minority groups Randomized controlled trial Adelaide, South Australia Home and community Phone and in person Dyads made up of people with dementia and their caregivers; caregivers were from a minority group, living at home Interdisciplinary team made up of 8 care coordinators, which included a registered nurse, a social worker, and 6 Community Home Care Certificate holders Care coordinator

N/A, not applicable.