Author, year	Title	Program description and services	Program barriers (barriers to implementation or delivery)	Program facilitators
Amjad et al.,32 2018	Health services utilization in older adults with dementia receiving care coordination: the MIND at Home trial	Maximizing Independence (MIND) at Home’s primary goals were to delay transition from the home and to reduce unmet care needs. The secondary goals included improving quality of life, decreasing neuropsychiatric symptoms, and reducing depression. The program provided services to clients, such as resource referrals, identifying and addressing potential environmental safety hazards, dementia care education, behavior management skills training, informal counseling, and problem-solving. They handled care needs, such as evaluation/diagnosis (primary care provider or specialist referral for dementia evaluation), treatment of cognitive symptoms and behavior management, referral to Alzheimer’s Association, medication administration, general medical/health care and safety, assistance with daily activities, legal issues/advance care planning, caregiver education, caregiver referrals, caregiver mental health care, and caregiver general medical/health care.	MIND care coordinators had difficulties establishing contacts with the respective health providers on behalf of intervention participants.	Integration, communication, and collaboration between the MIND care team and clients’ health providers.
Bass et al.,59 2003	The Cleveland Alzheimer’s managed care demonstration: outcomes after 12 months of implementation	Care consultants worked with families to help identify personal strengths and resources within the family system, health plan, and community to make an individual care plan. Often this included using other association services, such as education and training programs, support groups, a respite reimbursement program, and a nationwide program to return wanderers safely home. The program’s goal was to provide tools to enhance patients’ and caregivers’ competence and self-efficacy. Consultants also provided information about available community services, facilitated decisions about how to best utilize and apply for these services, and contacted service agencies on behalf of patients and caregivers. Standardized protocol for service delivery included conducting a structured initial assessment, identifying problems or challenges, and developing strategies for using personal, family, and community resources.	—	Collaboration and partnership with Alzheimer’s Association.
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	The Partners in Dementia Care care-coordination program was focused on integrating and improving access to medical and nonmedical services, while strengthening clients’ informal care network and providing information, coaching, and emotional support. There were two coordinators. The VA care coordinator also focused on helping families use VA services and benefits effectively, whereas the Alzheimer’s Association care coordinator focused on helping families use community services effectively. Standardized protocol included assessment and reassessment, action planning, and ongoing monitoring.	—	Shared electronic Care Coordination Information System; regularly scheduled planning and case-conference meetings; frequent contact with clients; and the low cost to deliver the navigation service.
Bass et al.,46 2014	A controlled trial of Partners in Dementia Care: veteran outcomes after six and twelve months	Partners in Dementia Care was a formal partnership between Veterans Affairs medical centers (a health care organization) and Alzheimer’s Association chapters (a community service organization). The care coordinator gave equal attention to veterans with dementia and their primary informal caregivers. The program was designed to facilitate holistic care; improve fragmentation and lack of coordination between medical care and community services; increase health care providers’ awareness about nonmedical needs of patients and caregivers; increase information and educational resources on dementia, its care, and illness-related strain; reduce difficulties accessing and monitoring services; and improve management of dementia with coexisting medical conditions.	—	Partnership between medical and community organizations.
Bass et al.,47 2015	Impact of the care coordination program “Partners in Dementia Care” on veterans’ hospital admissions and emergency department visits	Partners in Dementia Care was designed to coordinate health care and community services. This partnership promoted holistic, less fragmented care for the medical and nonmedical needs of individuals with dementia and their caregivers; increased attention to informal caregivers as fundamental to long-term care; increased access to information and educational resources; and improved management of coexisting medical conditions. The program had a standardized protocol and followed a coaching model.	—	Formal partnership between a health care organization and community service organization; increased attention to informal caregivers as the lynchpin of long-term care.
Bernstein et al.,22 2019	The role of care navigators working with people with dementia and their caregivers	The Care Ecosystem was a dementia-capable model that provides personalized and proactive care for people with dementia and their caregivers. People with dementia were assigned to a care team navigator, who identified needs and concerns; provided education and curated information about community-based resources; provided linkages to resources; provided care coordination; and provided emotional support by phone and email. Care team navigators also shared care planning and legal and decision-making tools, and provided tailored behavioral interventions. Behavioral interventions included providing, as needed, educational information about behaviors and instrumental help identifying resources, such as day programs or caregiver support programs.	Patient navigator burnout; the progressive nature of dementia; coordinating with primary care providers; and identifying resources for dyads who are low-income, do not speak English, and/or live in rural areas.	Working closely with caregivers; tailoring education and resources; and coordinating with a clinical team around issues ranging from clinical questions to financial and legal decision-making as facilitators.
Bernstein et al.,39 2020	Using care navigation to address caregiver burden in dementia: a qualitative case study analysis	Care team navigators, who were dementia specialists without medical degrees but received training, implemented the Care Ecosystem program’s care model. They worked directly with caregivers and patients, enrolled as dyads. Care team navigators identified needs and concerns. They provided education and information, linkages to resources, care coordination, and emotional support. They also coordinated with the clinical support team and other providers as needed.	—	Care team navigators had continuous contact with dyads by providing support and information; and the flexible delivery model enabled the Care Ecosystem to be more accessible and sustainable, with a broader reach.
Chen et al.,55 2020	Effect of care coordination on patients with Alzheimer disease and their caregivers	The Memory Program prioritized meeting both caregiver and patient needs by assisting with communication with their primary care physicians; providing licensed social worker services and other health care professionals for support, coaching, education, and referrals; creating a Caregiver Resource Library, an information source to learn about caregiving, managing stress, giving care, and topics related to memory health and self-care; and disseminating educational and supportive events led by experts in memory and geriatric care.	—	—
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	The Telephone-Linked Care for dementia program was modeled on the REACH program. Telephone-Linked Care offered access to resources and provided communication, support, education, and monitoring of caregivers, supplemented by access to the care coordinator and to a wide variety of community and Veterans Health Administration resources.	—	Veteran Affairs computerized patient record system, which provided access to medical information about the clients and facilitated care coordination and communication with the clients’ providers.
Dementia Waikato,66 2017	Dementia navigator service	Dementia Navigator Service provided initial information and education following a diagnosis of dementia, and then provided ongoing support, advice, and assistance to live well with dementia at home. It provided education about dementia symptoms and how to manage them; referral for professional assessment of any additional funded services; information and support about planning for the future; navigation through health system services; and ongoing contact by phone or visits as necessary, with a support coordinator.	—	—
Department of Veterans Affairs,67 2020	Rural Interdisciplinary Team Training (RITT) dementia care coordinator program	The dementia care coordinator provided one-on-on counseling, support, and education for caregivers of veterans with dementia. They helped caregivers connect to needed resources, apply for benefits, and navigate the health care systems. The program’s goal was to help caregivers reduce stress, improve problem-solving skills, and connect them to helpful resources. VA medical centers and VA community-based outpatient clinics referred caregivers to the program. Caregivers received 4-5 individual sessions based around assessment, instruction in stress-reduction techniques, and help with problem-solving.	—	—
Fæø et al.,53 2020	The compound role of a coordinator for home-dwelling persons with dementia and their informal caregivers: qualitative study	LIVE@Home.Path was a multicomponent, multidisciplinary intervention aiming to support dyads of people with dementia and their informal caregivers to live safely and independently at home. The program’s core components are learning, innovation, volunteers, and empowerment (LIVE). The education component included an optional educational course. The empowerment component involved the dementia coordinator coordinating the LIVE components and ensuring that the individual with dementia is empowered throughout the LIVE intervention process. The coordinator aimed to provide participants with care and support that was in line with their own perceived needs and wishes. The coordinator was a safety net, a pathfinder, and a source for emotional care and support. This function was flexible and ranged from giving basic information on available care and support to more or less taking over coordination of the many health and care services involved.	—	Flexibility and accessibility of delivery model allowed navigators to meet participants’ needs.
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	The Alzheimer’s Service Coordination Program was established to link primary care physicians in a partnership arrangement with a local branch of the Alzheimer’s Association that specialized in dementia care education and support services. The purposes of the program were to educate family caregivers about dementia symptom management; how to access community resources to enhance their own care; and to raise awareness among primary care physicians about community resources for people with dementia and their families. Physicians referred family caregivers to a service coordinator, who provided individualized consultation to family caregivers and people with dementia regarding all nonmedical aspects of dementia care and available resources in the community.	—	—
Galik and Stefanacci,69 2019	Improving care for patients with dementia: what to do before, during, and after a transition	The Alzheimer’s patient navigator helped people with dementia and their families plan to better manage the necessary medical care and social services. The navigators functioned across the continuum of care. They provided proactive care planning; caregiver support and education; and minimized unnecessary patient transitions. The program helped build communication skills with respect to cultural sensitivity and person-centered plans. The program also provided the necessary skills to help differentiate and navigate among the multiple systems and organizations involved in care.	—	—
Galvin et al.,56 2014	Public–private partnerships improve health outcomes in individuals with early-stage Alzheimer’s disease	Project Learn MORE (Missouri Outreach and Referral Expanded) was a multisite intervention consisting of comprehensive care consultations to improve coping skills. The program operated through referrals. Area Agencies on Aging care coordinators visited participants’ homes and conducted an assessment to determine eligibility for services such as nutrition and dining programs, care transitions, and case management services. Care consultations were an individualized 2-hour consultation with the care recipient and caregiver, conducted in a convenient location. The consultation included a comprehensive assessment and an individualized action plan to address client needs regarding coping skills, education, supportive services, planning for the future, and referrals to services (eg, legal advice, driving assessments). Social workers, physicians, or direct telephone calls from older adults initiated the referrals.	Difficulty coordinating efforts between community service partners to refer eligible clients for additional services.	Area Agencies on Aging computer database and AD8 dementia screening tool to identify older Missourians with dementia.
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	The specialist dementia nurse navigated clients through health care service systems. They provided culturally appropriate information to assist people with dementia and their caring unit to adjust to living with memory loss by educating them about dementia and the need for forward care planning; identified unmet needs; provided in-home strategies to manage changes in behavior to improve the quality of life of people with dementia and reduce caregiver strain; obtained culturally appropriate assessment and diagnosis; and acted as an advocate when necessary. Interventions included brochures translated into clients’ language, information on forward planning, accessing local council home care and personal hygiene services, incontinence advice, referral to consumer and caregiver advocacy groups, community assessment services, behavioral management services, music therapy, assistance in accessing financial reimbursements, and aids and assistive technology.	In some cases, available services and activities were not always compatible with participants’ needs.	The navigator’s ability to build trusting professional relationships, excellent assessment abilities, an in-depth knowledge of dementia, excellent interpersonal, listening, and advocacy skills. Tools such as the culturally and linguistically diverse dementia care pathway quick reference cards to guide engagement with the client.
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	LIVE@Home.Path was a multicomponent, multidisciplinary intervention aiming to support dyads of people with dementia and their informal caregivers to live safely and independently at home. The program’s coordinator facilitated learning, innovation, volunteers, and empowerment (LIVE). The coordinator facilitated participation in local educational programs. The innovation component consisted of the coordinator assessing and evaluating the usefulness of information and communication technology solutions that were already in use for the dyads and informing them about other relevant welfare technology available in the municipality. The coordinator also informed participants about new communication platforms that could meet needs of families organizing dementia care. For volunteering, the coordinator contacted and facilitated linkages between the dyads and volunteer organizations that can help them. For the empowerment component, the coordinator scheduled a meeting with the general practitioner to promote an empowered approach to advanced care planning. The coordinator conducted a minimum of 2 home visits and monthly phone calls.	—	—
Joels and van Pol,51 2014	How to manage follow-up patients: dementia navigators	This navigator model provided information about diagnosis; proactive referral to a range of resources (eg, health and social care, day service, third-sector support, benefits check, taxi-cards, well-being and housing, will-writing services); follow-up calls to confirm referral efficacy; and ongoing contact with services. They also scheduled reviews for those in need and wrote care plans, which were cc’d to general practitioners.	—	Program used a risk stratification tool to help determine intervention frequency and format.
Judge et al.,48 2011	Partners in Dementia Care: a care coordination intervention for individuals with dementia and their family caregivers	Partners in Dementia Care was a formal partnership between VA medical centers and Alzheimer’s Association chapters. It included a multidimensional assessment and treatment approach; ongoing monitoring and long-term relationships with families; and a computerized information system that guided service delivery and fidelity monitoring. The 4 main ways to assist patients and families were providing disease-related education and information; offering emotional support and coaching; linking/connecting families to medical and nonmedical services and resources; and mobilizing and organizing the informal care network. The program used an intervention protocol, assessment of care needs, development of care goals, development of action steps, and ongoing monitoring of action steps.	Perceptions of problems with the quality of Alzheimer’s Association services; quality of VA services; lack of knowledge of the Alzheimer’s Association services; lack of knowledge of VA services; and organizational financial problems limiting the success of Partners in Dementia Care, ability to share patient/family information between partner organizations, and overall challenges in collaboration between organizations.	The computer system; involvement of caregivers; initial and ongoing support from key leaders and site champions at both organizations; flexible communication model enabled maintenance of long-term relationships in a time- and cost-efficient way with clients; and scalable to rural areas.
Lee et al.,61 2014	Integrating community services into primary care: improving the quality of dementia care	Primary care collaborative memory clinics provided patients with comprehensive multidisciplinary assessments and a shared care and evidence-based approach to support timely access to quality dementia care. This included a needs assessment; referrals to other care providers; facilitation of linkages to other community services, such as Alzheimer Society of Ontario; and coordination of access to resources and services. Clinics had a partnership with the Alzheimer Society.	Concerns related to privacy and confidentiality issues associated with sharing patient information with an external service (these were resolved with the development of formal confidentiality agreements). Clinics faced some challenges establishing efficient strategies for maintaining effective communication between all team members; and initial struggles with the stigma associated with introducing someone from the Alzheimer Society before a diagnosis.	Training course provided to the clinics to improve the detection and management of dementia.
Liu et al.,68 2019	Patient and caregiver outcomes and experiences with team-based memory care: a mixed methods study	This single hospital-based memory clinic provided specialized memory care services using a team-based approach to diagnose and treat Alzheimer’s disease, related dementias, and other memory issues in older adults. The program focused on counseling patients and caregivers about diagnosis and disease progression; helping them work through economic and social concerns while navigating the medical system; and ensuring that providers receive information necessary for seamless care coordination. Each visit included a detailed interview with the patient and caregiver(s), medication reconciliation and review, comprehensive geriatric physical examination, functional assessment, goals of care discussion, social support and health literacy assessments, and depression/cognitive testing.	Patients and caregivers did not indicate they would reach out to the clinic as the first line of care for perceived unrelated medical conditions, so enhancing this program to include a memory care medical home could improve appropriate utilization of health care services in this population.	Incorporation of a navigator into the care team is a useful way to involve caregivers while providing protected space for both parties to express their concerns.
McAiney et al.,60 2012	‘Throwing a lifeline’: the role of First Link(TM) in enhancing support for individuals with dementia and their caregivers	The First Link initiative of the Alzheimer Society aimed to support individuals with dementia through a partnership between the Alzheimer Society and physicians, who referred people with dementia and their caregivers to the program. First Link referred them to community resources, education material, and support and coordination services. It encouraged health professionals to refer individuals to First Link at the time of diagnosis and accepted self-referrals as well. Individuals with dementia (or family members) who agreed to have their name shared with the Alzheimer Society were contacted by phone by the First Link coordinator.	In Saskatchewan, despite the ease with which referrals were made, the requirement for signed consent for the referral was identified as a significant barrier to referrals.	Linkages and partnerships with primary care physicians; and community resources and support helped increased clients’ access.
Merrilees et al.,40 2020	The Care Ecosystem: promoting self-efficacy among dementia family caregivers	The Care Ecosystem was a dementia-capable model providing personalized and proactive care for people with dementia and their caregivers. They were assigned to a care team navigator who identified needs and concerns. The care team navigator provided education and information, linkages to resources, care coordination, and emotional support and active listening. The proactive care protocols focused on issues critical to quality dementia care such as caregiver support and education, strategies for dealing with dementia-related behaviors, safety counseling, medication review, advance care planning, and links to community resources.	—	Adaptability of the program, which emphasized a multicomponent array of strategies and suggestions that could be personalized for each dyad, with flexible communication depending on dyad needs.
Morgan et al.,49 2015	A break-even analysis for dementia care collaboration: Partners in Dementia Care	Partners in Dementia Care was a telephone-based care coordination and support service for veterans with dementia and their caregivers. It was designed to be a feasible and practical intervention integrating health, community, and support services to address the unmet care needs of patients and their caregivers across all dementia stages. The service assisted families by providing disease-related education and information; offering emotional support and coaching; linking families to medical and nonmedical services and resources; and mobilizing and organizing the informal care network.	—	—
Morgan et al.,50 2019	Does care consultation affect use of VHA versus non-VHA care?	Partners in Dementia Care was a telephone-based care coordination and support service intervention for veterans with dementia and their caregivers. It was delivered through partnerships between VHA medical centers and local Alzheimer’s Association chapters. It was designed to integrate health, community, and support services to address the unmet care needs of patients and caregivers across all dementia stages.	—	—
Possin et al.,41 2017	Development of an adaptive, personalized, and scalable dementia care program: early findings from the Care Ecosystem	The Care Ecosystem was a scalable model of dementia specialty care that complemented primary care with additional caregiver support and education, medication consultation, and support in planning for future medical, financial, and legal decisions consistent with patient values. The role of the care team navigator was limited to include identifying gaps in planning (eg, identifying a health care agent); making legal referrals; preparing the family for a billable advance care planning appointment with their primary care provider; providing education and screening monthly for acute health changes; and providing emotional support/active listening.	Navigator burnout and stress; unclear triage protocols and the limits of using a non-licensed staff member as the first point of contact in delivering specialty care.	The navigators not being specialists/licensed health providers made them affordable.
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	The Care Ecosystem was a dementia-capable model, which provided personalized and proactive care for people with dementia and their caregivers. People with dementia were assigned to a care team navigator who identified needs and concerns. Care team navigators also provided education and information, linkages to resources, care coordination, and emotional support by phone and email.	—	Patient navigators’ flexible communication with clients, which makes the program scalable and accessible in rural areas; the program can be delivered from a centralized hub to clients either affiliated with multiple health systems or integrated within a single health system.
Rosa et al.,43 2019	Variations in costs of a collaborative care model for dementia	The Care Ecosystem used care protocols that guided navigators through caregiver support and education, medications, advance care planning, and behavior symptom management.	—	The cost of program implementation decreased substantially during the implementation periods and depended on caseload (minimum of 50).
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	MIND at Home was an 18-month care coordination intervention to systematically identify and address dementia-related care needs through individualized care planning, referral and linkage to services, provision of dementia education and skill-building strategies, and care monitoring by an interdisciplinary team. Coordinators reviewed the assessment, conducted an in-home visit with the participant and study partner to review and prioritize needs, and developed the care plan. A menu of care options/strategies was available for each unmet need and consisted of referrals and linkages to resources/services; caregiver memory disorder education and skill-building; and informal counseling and problem-solving. There were 2 in-home visits and monthly contacts. The intervention was designed to be deliverable through community-based aging service providers or service networks and link community-based care with a medical team.	—	Affordability of program.
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	MIND at Home’s intervention components included in-home dementia-related needs assessments, individualized care planning, implementation of standardized evidence-based care strategy protocols, and ongoing monitoring and reassessment.	Access to eligible clients, underdiagnosis, misinformation about dementia, stigma, isolation, cultural insensitivity.	Targeted outreach to potential clients, partnerships with nontraditional, nonmedical, and cultural-specific organizations; providing dementia education in local forums and use of proactive strategies to counteract underdiagnosis and raise awareness; aligning study objectives with unmet community needs and seeking input to obtain community stakeholder buy-in. To improve referrals: expand eligibility criteria, increase reminders about the study and eligibility criteria, and improve case identification knowledge.
Samus et al.,35 2017	Comprehensive home-based care coordination for vulnerable elders with dementia: Maximizing Independence at Home-Plus—study protocol	Maximizing Independence at Home-Plus (MIND at Home) was a new model of comprehensive home-based dementia care coordination tested in the United States. The program aimed to address delivery gaps, improve outcomes, and lower costs. MIND at Home-Plus systematically assessed and addressed a broad range of unmet dementia-related care needs that placed elders at risk of health disparities, unwanted long-term care placement, poor quality of life, and caregiver burden. MIND at Home-Plus services were delivered to participants for up to 24 months, with the primary end point for evaluation of impact on outcomes assessed at 18 months.	—	A set of tools that support the implementation and delivery of MIND-S, such as MIND at Home Intervention Handbook and Johns Hopkins Dementia Care Needs Assessment 2.0.
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	The Maximizing Independence at Home dementia care coordination program was a comprehensive, home-based care coordination intervention for people with dementia who lived in the community and for their caregivers. Intervention components included in-home dementia-related needs assessments, individualized care planning, implementation of standardized evidence-based care strategy protocols, and ongoing monitoring and reassessment.	—	A set of tools that support the implementation and delivery of MIND-S, such as MIND at Home Intervention Handbook and Johns Hopkins Dementia Care Needs Assessment 2.0.
Silverstein et al.,58 2015	The Alzheimer’s Association Dementia Care Coordination Program: a process evaluation, executive summary	In the Dementia Care Coordination program, care consultants connected directly with people with dementia and their caregivers who were referred to the Massachusetts/New Hampshire Alzheimer’s Association chapter by health care providers. The care consultant provided disease-specific education, symptom management strategies, emotional support, and referrals and linkages to community resources. They also encouraged the caregiver to utilize other Alzheimer’s Association services, including support groups, education programs, and advocacy opportunities. Consultants collaborated with other staff members and volunteers to provide ongoing information and support to families. Consultants provided written feedback to health care providers and nurse case managers on client needs and recommendations to meet those needs.	Consultants experienced issues in communicating with physicians, who work with different electronic medical record systems that have varying degrees of security and have differing preferences regarding their preferred communication methods – fax, phone, or email.	One way to manage the workload was to utilize dedicated volunteers, trained in the 24/7 Helpline and care consultation, to support the care consultants.
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	Maximizing Independence at Home, a community-based, multicomponent care coordination intervention, reduced unmet caregiving needs and burden in informal caregivers of persons with memory disorders.	While intended to empower caregivers, the intervention asked caregivers to take a larger role in the care of the person with dementia, which may have added additional stresses. It was possible that dyads and coordinators prioritized intervening on care recipient needs before caregivers needs.	—
Taylor et al.,62 2015	The Primary Care Navigator programme for dementia: benefits of alternative working models	The Primary Care Navigator for dementia role provided support for people with dementia who were both pre- and post-diagnosis. The primary care navigator was trained to listen and guide people to the support and resources they needed from local and national services. Organizations developed the roles according to the needs of each site. They created care plans and supported physicians and nurses. At the Gateshead site, the primary care navigator developed a directory of services.	—	Full engagement from the outset, together with continued leadership from the practice; a collaborative approach; agreeing individual care plans and assigning general practitioners.
Tjia,44 2019	A telephone-based dementia care management intervention-finding the time to listen	The Care Ecosystem was a dementia-capable model that provided personalized and proactive care for people with dementia and their caregivers. People with dementia were assigned to a care team navigator who identified needs and concerns, provided education and information, supported linkages to resources, provided care coordination, and provided emotional support by phone and email.	—	Navigators’ strong communication and listening skills, responding to caregivers’ immediate needs and then screening for common problems and providing personalized support; telephone provided flexible and accessible communication; program was scalable across economic, and health system boundaries.
Willink et al.,38 2020	Cost-effective care coordination for people with dementia at home	Maximizing Independence at Home was a home-based dementia care coordination program administered by trained, nonclinical community workers as the primary contact between people with dementia and their caregivers, supported by a multidisciplinary clinical team with expertise in dementia care. It systematically assessed and addressed a broad range of unmet dementia-related care needs for people with dementia and caregivers that place older adults at risk of health disparities, high health care costs, poor clinical outcomes, poor quality of life, and caregiver burden.	—	Cost-effective; scalable; collaboration between medical organizations, community resources, patients, and families.
Wood et al.,52 2017	A holistic service for everyone with a dementia diagnosis (innovative practice)	The Dementia Navigator Service was built on the existing Dementia Advisors Model operated by the Alzheimer’s Society to provide signposting to services and assistance to navigate the health and social care systems. This service aimed to reduce social isolation; monitor and manage risk; promote effective communication and partnerships by working between health and social care and third-sector providers; provide a person-centered responsive service to everyone in the borough with dementia living in the community; and enable people living with dementia and those who care for them to access the services they need to avoid crisis. Most referrals to the Dementia Navigator Service were received following diagnosis by the Memory Assessment and Treatment Service.	—	Liaising with general practitioners, social workers, and those working in the nonprofit sector facilitates access to appropriate health and social care services in a timely manner to prevent crises.
Xiao et al.,64 2016	The effect of a personalized dementia care intervention for caregivers from Australian minority groups	A community care coordinator-led personalized dementia care intervention for caregivers from 10 minority groups. “The Inventory of Carer’s Needs” listed 5 areas of caregiver support: information needs, educational and skill needs, environmental safety needs, social-cultural care needs, and self-care needs that reflect the current research evidence in dementia caregiver support. The coordinators used a Personalized Caregiving Support Plan to assess caregivers’ needs. They provided regular and frequent visits to assess needs. They referred caregivers to new services and education programs based on this needs assessment. When necessary, they organized conferences with caregivers and care staff to discuss ongoing challenges. The usual caregiver support included activities such as monthly caregiver support group meetings and information sessions that were funded by the National Respite for Carers Program.	—	Two instruments, the Personalized Caregiving Support Plan and a “caregiving diary”: the use of the caregiving diary allowed care staff to identify care needs of care recipients and provide face-to-face coaching with caregivers and evaluate the effectiveness of care staff’s actions.

VA, Veterans Affairs.