The average dementia patient lives with symptoms of the disease for over ten years, the majority of which is spent living at home. As a result, it is critical for providers to manage patients at home at the onset of the disease in order to reduce the need for excess utilization down the road.
The Center for Memory Health at Hebrew SeniorLife
Hebrew SeniorLife (HSL), a senior services organization based in Boston recognized this need to provide more cohesive support to dementia patients in the community. In April 2019, it opened the Center for Memory Health to serve as the hub of its memory care programming, which already included assisted living, adult day, and home health care.
The Center for Memory Health at Hebrew SeniorLife provides four core services to dementia patients and their caregivers.
Patients and their caregivers can visit the Center for a one-hour consultation session with a social worker or geriatric psychologist. At the session, staff perform a cognitive assessment, discuss the patient's history and goals, and refer the patient and caregivers to additional services as needed.
Patients without a clinical diagnosis of dementia can also complete neuroimaging testing on site or through one of HSL's partner providers. A clinical diagnosis is required for entry into the Center's care management program.
3. Care Management.
The heart of the Center's offerings is its care management program, which is based on the UCLA Alzheimer's and Dementia Care Model. The program is a care management model led by nurse practitioners (NPs) that engages the patient, a family caregiver, and a primary care physician or specialist in a long-term care plan.
A typical care plan includes home safety modifications, referrals to community resources, advanced care planning, education sessions, and/or medication adjustments. In addition to the interventions included in the care plan, patients and their caregivers receive ongoing support through quarterly check-in calls with the NP, access to an emergency support line, and yearly follow-up visits, at minimum.
4. Caregiver Support.
Lastly, the Center offers a counseling service for caregivers of patients with memory loss. Through the program, caregivers meet with social workers to learn how to better manage both patient care and their own stress.
By providing these four services together, HSL is able to support dementia patients and their caregivers throughout—and at any stage of—the course of the disease. In doing so, they are better equipped to identify changes in patient condition and position themselves as the provider of choice for residential memory care services, should the need arise.
Five elements of an effective memory care management program
Although not every provider may be able to make the investments that Hebrew SeniorLife did to create their Center, there are five key elements of the program that can be applied to any memory care management model:
- Include a multidisciplinary care team, with social work and clinical support.
- Provide both stress management and disease-specific education to caregivers.
- Check and modify the patients' home to reduce the risk of falls and wandering.
- Have a dedicated line for on-demand support for patients and caregivers.
- Refer patients to community resources, such as Memory Cafes, adult day, or local Alzheimer’s Associations.
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