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Aging Brain Care (ABC) Program

an older asian couple sits together on their couchMore than three million people with dementia experience cognitive, functional, behavioral and psychological disabilities. Dementia generates significant financial and emotional stress for both the person with dementia and their unpaid caregivers.

The Aging Brain Care (ABC) program is an evidence-based population brain health management program that uses an interdisciplinary care team to improve the brain health of community dwelling adults at risk for cognitive impairment or those living with Alzheimer’s disease and related dementias (ADRD). The program is rooted in collaborative care and includes the patient’s care partner(s) and the patient’s primary care team.

The ABC Program has been operating for 15 years at Eskenazi Health. Unique characteristics of the ABC model include home-based assessments of caregiver stress and patient cognitive, behavioral, psychological and functional status coupled with protocol-driven interventions. All interventions are done in collaboration with the primary provider—the ABC model does not assume care of the patient but rather brings additional resources to the table for the primary provider.

The Aging Brain Care program meets Guiding an Improved Dementia Experience (GUIDE) Model requirements—a model test that aims to support people living with dementia and their unpaid caregivers.

ABC Services

Care Coordination and Management

Management of dementia and co-occurring conditions delivered by an interdisciplinary care team: geriatrician or primary care provider, social worker and care coach.

Caregiver Education and Support

  • ABC care coach receives 40 hours of training.
  • ABC care coach delivers caregiver skills training and education.
  • ABC care coach routinely completes the Healthy Aging Brain Care (HABC) monitor to assess caregiver’s stress. Results guide which care protocols should be used. 
  • ABC care coach completes the evidence-based Caregiver Stress Prevention Bundle (CSPB) centered on support group participation, problem solving, and crisis planning.

Respite Services

The caregiver receives eight hours per week of respite.

Program Effectiveness

The Acute Care Service Utility Domain  ABC Routine Primary Care 
% patients with at least one ER visit 28%


Total number of ER visits 124


% patients with at least one hospitalization 13%


Total number of hospitalizations 45


Mean/Median length of hospital stay 5 / 4

7 / 4

Boustani et al, Aging & Mental Health 2011

Implement the ABC program

The ABC implementation team provides:

  • Technical assistance
  • Education and training
  • Access to developed materials and protocols
  • Sustainability support

Implementation tools include training for dementia care coaches to deliver caregiver coaching, Healthy Aging Brain Care (HABC) Monitor and caregiver protocols.

HABC Monitor measures the burden of ADRD related disabilities and assists in tailoring the caregiving coaching.

Interested in implementing ABC?

Please reach out to Shannon Effler, associate director of imAGE, to develop your implementation package.