The Allen Hospital, where Granieri practices, is a community hospital serving northern Manhattan, the Bronx, and parts of New Jersey. For patients over the age of 70, the hospital offers geriatric consultations for nursing units at the hospital, an outpatient practice, and a house call program for patients who are too frail to come into the hospital or physician's office. Granieri says more than 300 patients, on average, receive services from an interdisciplinary team that includes social workers, nurse practitioners, and five fellowship-trained, board-certified geriatricians.
"Our practice is small," she says, and describes the patient population in the primary care practice as very frail. "We don't take care of healthy old people. We take care of people who … have to be over 70, they have to have some other markers of frailty, and the most consistent of them is that they have cognitive disorders."
One of the barriers to coordinating care for patients with dementia is the dwindling number of geriatricians, and the general unfamiliarity with dementia on the part of nonspecialists. But New York-Presbyterian, with its affiliation with Weill Cornell Medical College and Columbia University College of Physicians and Surgeons, is helping change that, says Granieri. She gives oversight to the medical residency rotation in geriatric medicine. There are about 50 internal medicine residents who get a chance to see the team-based approach to geriatrics and dementia care.
"We've now taught almost eight years' worth of residents, and they get it," she says. "The environment is not always helpful for them because they get pressured by other clinicians to do extra things that may not be necessary, but they understand which medications older adults should not have. There are physicians now who have been exposed to and participated in what we like to think of as optimal care of older adults with cognitive impairment."
Success key No. 2: Treat the family, not just the patient
Lee Memorial Health System, a Fort Myers, Florida–based public health system with a medical group and 1,423 beds among four acute care and two specialty hospitals, expanded its services for patients with memory issues, including dementia, three years ago with the addition of a house-call program and a 112-bed skilled nursing facility, HealthPark Care & Rehabilitation Center. Lee Memorial's memory care program is aimed at taking care of patients with dementia in a more coordinated way, starting with screenings in the community. For 10 years, a volunteer nurse has been screening seniors in southwest Florida for free every Monday morning.
"Catching people as early as possible so we can monitor them for a significant drop in memory is very important," says Sunny Kozak, practice manager for the Lee Physician Group Memory Care, House Calls, and Geriatrics Service program. "We are seeing an increase in people coming in at a younger age. Instead of waiting until the late 60s, early 70s, they're coming in at their mid-60s."
As a designated memory disorder clinic for the state of Florida, Lee Memorial must reach a state-imposed benchmark of 100 screenings annually, which they exceed every year. From July 2012 to June 2013, Lee Memorial Health System completed 145 free screenings. Only 8% were 65 years or younger. From July 2013 through December 2013, there were 35 free screenings, a low number that staff attributes to the holidays; however, the younger age group already accounts for 8% of screenings with six more months to go.