Dementia Care Management

People with dementia and their families are at the heart of Dementia Care Management (DCM): This term refers to a concept designed to provide the best possible care in the patient's home environment, based on individually tailored healthcare. From the initial diagnosis through to the need for care, affected families receive support so that they always get the help they need. This assistance can significantly improve quality of life and ensure that patients can continue living independently in their familiar surroundings for a longer time.

The concept was developed at the DZNE and is closely monitored by experts far beyond Germany’s borders due to its model status. At its core, the goal is to identify early which type of support patients and their families need. These needs vary greatly depending on life circumstances—and they fall under the purview of numerous different stakeholders: Some tasks can be handled by a home care service, others require a doctor, and coordination with various government agencies, health insurance providers, and social security offices is also necessary.

The primary goal: a longer, self-determined life with the highest possible quality of life

Specially trained Dementia Care Managers serve as the central contact persons for affected families within the concept. They establish a local network that brings together the various stakeholders, assist with coordination, and provide advice—and, drawing on their experience with similar cases, they can offer many practical tips. This reduces the need for further medical consultations and simultaneously relieves the burden on primary care physicians. The concept also demonstrated that, thanks to this care, patients had fewer hospital stays.

The origins of the DCM date back to 2011: At that time, the Delphi-MV study was launched at the DZNE’s Greifswald site, marking the first time such specialized care was tested and evaluated. In the meantime, the results of numerous other studies (see end of text) building on this are now available—in this veritable cascade of projects, the DCM has been continuously improved or adapted to different regions. A constant companion is an IT-based care management system that automatically helps to identify needs and suggests an action plan. In this way, nothing escapes the attention of the specialized nursing staff. In the latest study, Living@Home, the concept is supplemented by an app for family members. This app is designed to ensure a constant connection between the affected families and the expert center and to offer assistance precisely when needs or domestic crises arise.

Effectiveness Scientifically Proven

In Germany, there are an estimated 1.8 million people with dementia. The DCM is currently awaiting nationwide implementation. It has been tested and continuously improved in four federal states (Brandenburg, Hesse, Mecklenburg-Western Pomerania, and North Rhine-Westphalia) as part of pilot projects involving several thousand participants. These pilot projects were designed by researchers at the DZNE and monitored in extensive studies over many years. This demonstrated that the DCM is effective: it improves patient care and relieves the burden on family members. Family physicians participating in the studies found the concept to be very supportive. At the same time, it was shown that there are fewer unmet needs and that the number of hospital stays can be reduced. Within the first two years, patients were also able to remain at home longer, which delayed any potential admission to an institutional care facility. These effects were achieved without increased costs.

Because of these successes, DCM is anchored in the National Dementia Strategy as well as in the treatment guidelines. The Joint Federal Committee (G-BA), the highest decision-making body of the joint self-governing bodies in the German healthcare system, also recommended the integration of DCM into standard care. For this final step, policymakers must now take the necessary steps.

Relevant papers

DelpHi-MV
doi: 10.1186/1745-6215-13-56.
doi: 10.1017/S1041610214000830. 
doi: 10.1001/jamapsychiatry.2017.2124.
doi: 10.1016/j.jalz.2019.05.008.
doi: 10.1001/jamanetworkopen.2024.19282.

Intersec CM
doi: 10.1186/s13063-021-05021-1.
doi: 10.1093/ageing/afaf011.

GaiN
doi: 10.1186/s13063-021-05395-2.
doi: 10.1016/j.jval.2025.01.011. 

DCM:Impact
doi: 10.3233/ADR-220045.
doi: 10.1007/s41669-024-00548-w.

Routine DCM
doi: 10.1136/bmjopen-2024-085852.

InDePendent
doi: 10.1186/s13063-022-06249-1.
doi: 10.1002/alz.70727.

Living@Home
doi: 10.1186/s13063-026-09639-x.

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