A High Needs ACO for Dementia

An extra layer of support
for the most complex
patients and families.

We are a Medicare Accountable Care Organization built around the specific needs of older adults living with dementia and the families who care for them. We bring the doctor, the nurse practitioner, the social worker, the pharmacist, and the chaplain to the patient — in the clinic, in the home, and on the phone 24/7.

7
Disciplines on every care team
24/7
Advanced practice provider coverage, every day of the year
1:1
A dementia-trained navigator who knows your family by name
★★★★★
Neurology expertise — partnered with the nation's top neurologists
An ordinary afternoon, kept ordinary
Why M&R Exists

A program for the disease we kept failing.

We were built by clinicians and operators who had spent years inside the broader Medicare value-based care world — and kept watching the same thing happen. The patients who needed the most care were the ones the system was least built to help. A woman with mid-stage Alzheimer's would end up in the emergency room with a urinary tract infection that a phone call could have caught. Her daughter would lose three days of work and a piece of her own health holding the family together. And the medical chart would record only the admission, not the failure that preceded it.

Dementia is the disease that exposes everything fragmented about American healthcare. It is long. It is expensive. It is rarely the only diagnosis. It demands coordination across primary care, neurology, pharmacy, social work, spiritual care, and the family kitchen table — and the standard fifteen-minute primary-care visit cannot deliver any of it. The cost of that mismatch is paid in hospital admissions, in caregiver collapse, in placements that should have been delayed by years, and in deaths that arrive in the wrong room.

We started this program to build what we wished had existed for our own families. Our model is grounded in the strongest published dementia care evidence and a team with extensive experience helping patients and caregivers through tough clinical journeys.

The Care Model

One team, around one family,
across the whole disease.

Most dementia care is delivered in fragments. A primary care visit here, a neurology consult there, a hospital admission that nobody knew was coming. We are built differently — an interdisciplinary team that meets every week, knows every patient, and is reachable any hour of the day.

i.

Medical leadership

A medical director leads each, backed by the nation's top neurologists, and advanced practice providers who carry the day-to-day clinical load.

ii.

It's a team sport

Social work, pharmacy, nutrition, behavioral health, and spiritual support, with a care navigator who knows the family by name.

iii.

Care in the home

Visits in the home are not the exception — they are the default for patients who can no longer easily come to a clinic, and for every patient at end of life.

iv.

24/7 access

Around-the-clock care from a dementia-trained team, with same-day or next-day visits in the clinic or home when necessary. The goal is to keep patients and families out of the emergency room.

v.

Neurology partnership

Built in conjunction with the nation's largest neurology practice — for diagnostic precision, complex co-management, and disciplined use of new therapies.

vi.

Support for caregivers

Family caregivers are positioned as members of the care team — trained, supported, and never alone with a crisis. Respite, education, and a real person to call.

Get in Touch

For families, referring clinicians, and partners.

Whether you're a family looking for help, a primary care physician with a patient who needs more than a fifteen-minute visit can deliver, or an organization exploring partnership — we'd like to hear from you.