If the screening indicates further testing is warranted, the providers tell the person who was screened "gently."
"It's a screening examination, not a diagnostic test," says Avra Bowers, MD, MBA, system medical director of primary care and community health services at Lee Memorial Health System, who is overseeing memory care at the system level. "We handle it very gently and advise them to get a full evaluation with a referral coming from the PCP because we do think it's extremely critical that the primary care doctor who is going to handle their other issues and medical conditions is involved in the full understanding of the potential dementia diagnosis and what we need to do next."
The memory care screenings are staffed by Lee Physician Group providers, but aren't limited to LPG patients. That's because the hospital system views dementia as a communitywide issue.
"We try to keep a healthy pulse on the patient's dementia progression and their needs from a safety perspective," says Kozak, noting that it's important to continuously monitor patients, sometimes for years, to determine what kind of care is appropriate. If the patient's memory problems are progressing, Lee Memorial can suggest adult daycare, home care services, or long-term care placement to try to prevent a hospital visit. "Hospitalization for patients with memory impairment, unfortunately, often turns into a worse situation than it needed to be," Kozak adds.
Similar to New York-Presbyterian, Lee Memorial assembles a team to help care for patients with dementia. It includes three geriatricians, two neuropsychologists, an advanced registered nurse practitioner, a social worker, and case managers who are embedded at 17 of LPG's primary care offices. The case managers are part of Lee Memorial's goal to attain patient-centered medical home status, which Bowers says helps coordinate care for dementia patients once they're diagnosed. But one of the most important members of the care team is the caregiver.
"We're essentially caring for two patients," says Kozak. "The most important thing we try to do is not allow that patient and caregiver to silo themselves from everything, which is the natural tendency. Alzheimer's is a family disease. We actually invite the caregiver and family members to come in for every appointment."
If an LPG patient with dementia is admitted to a Lee Memorial hospital, one of six ARNP liaisons follow patients into the hospital and communicate back to memory care staff and LPG doctors. These ARNP liaisons are assigned to one facility each, which is important for patients with memory and cognition problems. The liaison becomes a familiar face to the patient and the patient's family, making sure the patient's needs are met, questions are answered, and information is shared between hospitalists at the facility and the primary care physician.
Bowers says Lee Memorial has not started tracking readmission rates on this population, but attests to the seamless care.
"It's all about the patient; it's about the family members and helping them through it because it is critical for the quality of care for the patients."