GENERATIONS – Journal of the American Society on Aging

CBOs that provide additional social resources. The program uses a nurse practitioner dementia care specialist, with guidance from a physician dementia specialist, who tailors and facilitates dementia care delivery in partnership with the primary care or specialty physician (co-man- agement). Nurse practitioners can write orders, communicate directly through the electronic health record (EHR), and facilitate clinical care. Each dementia care specialist has a panel size of 250 patients and their caregivers and, currently, four dementia care specialists care for approxi- Many clinicians have neither the time nor, in some cases, the skills to adequately manage aspects of dementia. mately 1,000 patients. Although this may seem to be a heavy caseload, dementia care specialists have managed these caseloads for six years and are supported by assistants who help with stable patients. Key components to the UCLA ADC include the following: Recruiting patients to the program and UCLA dementia registry . Patients are recruited into the program through referrals from the UCLA primary care, geriatrics, psy- chiatry, and neurology practices. We are also developing EHR prompts to encourage physi- cians to refer patients with dementia who are high healthcare services users. To enroll in the program, the person must have a diagnosis of dementia and a UCLA physician who will part- ner with and respond to recommendations from the program. Patient and caregiver are given struc- tured needs assessments . Participation in the program begins with an in-person 90-minute visit with a dementia care specialist, the patient, and at least one family member or primary care- giver. To prepare for the visit and ensure it is effi- cient, people (if in the early stage of dementia)

and-or their caregivers are asked to complete a pre-visit intake form ( Creation and implementation of individ- ualized dementia care plans . Based on these initial assessments, the dementia care special- ist works with the person and family to draft a personal care plan that is sent to the referring primary care physician for approval or modifica- tion. This EHR-delivered information is divided into medical recommendations that the primary care physician is asked to address (and respond to through the EHR) and social and behav- ioral recommendations that the dementia care manager implements independently. When the dementia care specialist has received a response from the partnering physician, the assessment note is finalized and saved to the EHR. The per- son and-or caregiver then receives a copy of the care plan and a phone call from the dementia care specialist to discuss final recommendations. All people and their families receive ongoing dementia care management by a dementia care specialist, tailored to their specific patient and caregiver needs and may include the following: √ In-person sessions at which the person’s and family members’ specific questions about problems, resources, and implementing care plans are answered; √ Telephone follow-up to monitor implemen- tation of dementia care plans; √ Facilitation of appointments with consul- tants when needed; and √ Teaching dementia management skills to caregivers through individual counseling, includ- ing information on legal and financial planning with referral to community services; behavioral techniques to avoid or manage behavioral prob- lems; and coping strategies for caregivers. If the person with dementia is hospitalized, patients and their families receive the following: Communication with the hospital team within 48 hours of admission, including advice on managing dementia-related behaviors, participat- ing in goals-of-care conversations, and facilitating discharge planning and transitions to home;

64 | Spring 2019

Made with FlippingBook Learn more on our blog