"For example, if you're a front office manager and Mrs. Jones comes to see the doctor on the wrong day, and she's 70 years old, and she forgets her prescriptions, that should be a warning sign," says Allen. "If we don't train the office staff to do it, they'll just say, 'She's just a confused little old lady.' "
If approved, the grant would fund advanced practice providers, such as a nurse practitioner or physician assistant in Riverside's primary care practices, who would be what Allen describes as a dementia care manager. They've already been piloting practice guidelines and tools in one of its practice locations since November 2013.
"What we've seen is that it takes a lot of time," says Allen. "The challenge is the time, the energy, the training, and how do we scale this across 30 practices?"
We have prepared a grant application that we will send to funding agencies to aid in Riverside Health System's approach to memory care issues. The system's Lifelong Health division is dedicated to the medical conditions that arise from caring for an aging population.
With more than 2,500 employees, the division cares for more than 6,000 older adults daily in their service area, which covers more than a dozen counties in eastern Virginia. There are five fellowship-trained geriatricians on staff, and they plan to hire two more. Allen says 40% of its dual-eligible population has dementia as a diagnosis, and in general, 5% of patients over 65 have some form of cognitive impairment that increases each decade over the age of 65.
Its dedicated program for patients with dementia is called ClearPath, an integrated service model that aims to help patients and families understand what it means to have and live with dementia.
The ClearPath model began developing in 2009 with its memory care households, which are assisted living and long-term care facilities designed to feel like home instead of an institution.
There are five such households. They are small, with only 20 residents, and are meant to be that way so that the space is not overwhelming. The residents have private bedrooms and bathrooms, but there is a common dining hall and kitchen. The smaller, home-like setting of these residences reduces anxiety in patients and families.
"The goal is to enhance dignity and provide the best quality of life possible while offering peace of mind for families," says Bob Bryant, senior vice president of Riverside Health System's Lifelong Health division.
In addition to residences, Riverside's ClearPath program also includes adult daycare, home care, and community-based care.
Bryant says they view a patient with dementia holistically and believe that community organizations, such as the Alzheimer's Association and Area Agencies on Aging, play a key role with the health system and families.
Families of dementia patients often will lean on advocacy organizations for help in securing resources, such as respite care options, education about the disease, or support groups, but Riverside Health also benefits from such partnerships.
Eastern Virginia Care Transitions Partnership—a coalition of five health systems, including Riverside Health, 11 hospitals, and five Area Agencies on Aging—helps patients transition from hospital to home with a health transitions coach. The coaches are funded by federal dollars that are awarded to community-based organizations, which means there is no financial outlay for Riverside Health.
"This is very different from case management," says Allen. "With the Eastern Virginia Care Transitions Partnership, they have a whole way of motivational interviewing that kind of teaches the patient how to manage their own conditions.
"The coach sees them once in the hospital, once at home, and then there are two phone calls. It's a 30-day intervention, and has been very effective at reducing 30-day readmissions by 9%–10%."
Riverside Health is attempting to build a longitudinal continuum of care for patients with dementia that improves the quality of life for the patient by bringing together clinicians and communities.
"It's a team-based approach; it's about getting the physicians, nursing, social workers, and the families together as a team around these illnesses and doing it in a way that we improve quality, service, and reduce costs," says Bryant. "We need to continue the innovation of new services, programs, and models of care that can deliver on the triple aim of improved outcomes, better experiences, and reduced costs."
This article appears in the June 2014 issue of HealthLeaders magazine.