Georgia StARS Project (GSP)

• Lead: Kristi Fuller, Georgia State University
  
• Partners: Georgia Department of Human Services Division of Aging Services (DAS); Georgia Memory Net (GMN); Georgia Department of Community Health (DCH); Georgia Department of Public Health (DPH); Georgia Area Agencies on Aging (AAAs)
  

The Georgia StARS Project focuses on strengthening the state’s ability to track service delivery and support individuals living with dementia by enhancing data integration across clinical and community-based systems. The project will assess and align data from the Division of Aging Services’ (DAS) WellSky Human Services data platform that manages all older adult programs; data from the Community Care Services Program (a Medicaid waiver program); referral and diagnostic data from Georgia Memory Net that focuses on early dementia diagnosis and referral; and relevant public health datasets to develop a standardized data crosswalk and improve interoperability. Currently, these systems operate independently, limiting the ability to close referral loops, monitor service utilization across settings, and evaluate outcomes beyond DAS-administered services. Through partner convenings and facilitated collaboration, the project will identify shared data elements and address barriers to data exchange. In parallel, regional Lived Experience Panels from across Georgia will provide insights from individuals living with dementia and their care partners to inform system design and ensure responsiveness to real-world needs. These efforts will support improved coordination between healthcare providers and community organizations; earlier identification of individuals with cognitive decline, enabling more comprehensive tracking of referrals; and more informed decision-making to enhance dementia care statewide.

Maryland StARS Project (MSP)

• Lead: Leigh Ann Eagle, Maintaining Active Citizens, Inc’s (Area Agency on Aging for the Lower Eastern Shore of Maryland) Living Well Center of Excellence
• Partners: Maryland Department of Health (MDH); Maryland Department of Aging; Chesapeake Regional Information System for our Patients (CRISP); Johns Hopkins Geriatric Workforce Education Project

The Maryland StARS Project will identify and standardize data across key statewide dementia-related services to enhance bi-directional communication between community-based organizations and healthcare providers. Specifically, the project will identify and integrate data across four data systems: CRISP, which manages and distributes patient data across hospitals and other healthcare providers; CCS Health, a billing system for the CMS Guiding an Improved Dementia Experience (GUIDE) model; Findhelp Maryland, a referral system listing aging, health, and social services; and Athenahealth Electronic Health Records, which interfaces with CRISP. CRISP will be the primary tool used to query client health care outcomes and return on investment. Currently, these systems are not connected, limiting patient referral and the ability to quantify health impacts and cost savings. The new bidirectional data and referral system will allow aging, disability, and social service networks to coordinate service delivery with clinical providers. Aggregate data will leverage and enhance the Maryland Department of Health dementia dashboard, which will provide information on statewide dementia incidence and people living with dementia/caregiver service needs.

Virginia Integrated Systems for Tracking Alzheimer’s Care (VISTA)

• Lead: George Worthington, Dementia Services Director, Virginia Department for Aging and Rehabilitative Services
• Partners: Virginia Commonwealth University; Riverside Health; University of Virginia

The Virginia StARS Project will develop a structured, sustainable process to link and harmonize data collected by various dementia care management programs operating in the state. Specifically, it will link data from four state-supported dementia care management programs with the Virginia Memory Project, which is Virginia’s Alzheimer’s and dementia registry that houses paid medical and pharmacy claims data from the All-Payer Claims Database. Data from the programs run by the University of Virginia’s Memory and Aging Care Clinic, the Martha W. Goodson Center at Riverside Health, the Span Center in partnership with the Richmond Brain Health Initiative at Virginia Commonwealth University, and the Local Office on Aging (LOA) in partnership with Carilion Clinic Center for Healthy Aging, will be used to analyze and compare outcomes from structured dementia care management. This project will integrate these data systems to improve data sharing and enable analyses to guide state decision-making.