Care Transformation Center Blog

How Hebrew SeniorLife is managing the growing dementia population—and how you can too

by Carolyn Buys and Monica Westhead

The number of patients with Alzheimer's and other forms of dementia is expected to grow from 5.8 million to 14 million by the year 2050, costing the U.S. health system nearly $800 billion. These patients have twice as many hospital stays as other older adults, and present unique clinical challenges to providers, such as frequent wandering and ED utilization.

Learn more about the 5 elements of an effective memory care management program

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. 

1. Consultation. 

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.

2. Diagnosis. 

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:  

  1. Include a multidisciplinary care team, with social work and clinical support.

  2. Provide both stress management and disease-specific education to caregivers.

  3. Check and modify the patients' home to reduce the risk of falls and wandering.

  4. Have a dedicated line for on-demand support for patients and caregivers.

  5. Refer patients to community resources, such as Memory Cafes, adult day, or local Alzheimer’s Associations.
 

Subscribe to The Care Transformation Center Blog

To get more of our top insights, make sure you're subscribed to the "Care Transformation Center Blog."

Subscribe to The Care Transformation Center Blog

Explore 4 steps for building effective community partnerships

To be successful, population health programs must invest heavily in partnerships with local organizations and health departments.

Learn how to develop and leverage these partnerships to address the root causes of local health challenges.

Download Now