Friday, May 3, 2024
5/3/2024
Indian Health Council, Inc. (IHC), a healthcare consortium of nine North San Diego County, California tribes, will plan and implement a multi-level comprehensive approach to care and services for AI/AN persons living with dementia and their caregivers. Building on the existing strategies and resources developed by IHC to provide basic primary care for elderly patients, our goal is to create a cohesive model that supports early detection of dementia based on an integrated case management system and community-of-care model that assures timely delivery of screening, diagnosis, client-centered care planning, monitoring, caregiver support, and access to specialized services. The program will address these areas: Awareness and Recognition. A Nurse Case Manager (NCM) will train front-line provider staff in other departments in the warning signs of dementia. IHC will increase community knowledge about dementia through an online social media community that receives information and shares concerns about such issues as: the warning signs of Alzheimer’s and other forms of dementia; the importance of early/annual screening for individuals age 65+ during Medicare Wellness Examinations; medications available; and local resources. The NCM and a Public Health Nurse (PHN) will adapt culturally appropriate outreach materials for distribution at community venues or events and during home visits. Accurate and Timely Diagnosis. To address the challenge of providing timely screening, we will adopt the Mini-Cog© test as a precursor to a more comprehensive diagnostic workup at the clinic using the SLUMS assessment tool. Interdisciplinary Assessment. IHC will establish a standard approach to interdisciplinary assessment of persons with cognitive impairment and development of a comprehensive care plan. Management and Referral. Nurse Case Manager (NCM) will assure patients with dementia, including those who have co-morbid medical conditions, receive appropriate levels of treatment during disease progression, ongoing monitoring by a PHN and/or NCM, and access to medical or other departmental services when needed. Support for Caregivers. Caregivers will be supported by: 1) In-home visits by the PHN to monitor caregiver status and provide coaching on patient care, problem-solving for difficult behaviors, and self-care for the caregiver. 2) Assistance in navigation, scheduling visits, managing prescriptions and medications. 3) Referral to local resources, including placement facilities and caregivers support groups that may assist with respite needs. IHC will also provide ongoing data collection and evaluation of ALZ program model, quarterly trainings to assure support for clinicians, and identification and implementation of funding streams to support service delivery and facilitate sustainability.
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).
