Norton Sound Health Corporation Dementia Services Coordination Program - The Norton Sound Health Corporation (NSHC) proposes to develop an increased clinical capacity to coordinate thorough and timely services for those persons experiencing cognitive impairment through Alzheimer’s Disease and other Related Dementias in the Bering Straits region. The region includes the hub town of Nome, Alaska and 15 regional villages, with a combined population of just over 10,000. NSHC provides health care, including Acute Care, Primary Care, and therapies through the Norton Sound Regional Hospital in Nome, primary care services through village clinics utilizing Community Health Aides, and an 18-bed Long Term Care Center. NSHC hosts specialty providers from the Alaska Native Medical Center such as Neurology, etc. to increase patient care resources. NSHC also provides in-home support, personal care provision and case management through its In-Home Programs. NSHC has identified some program service gaps that it proposes to address under this grant. The first is that people in the region do not always recognize the signs of dementia early enough to allow those patients and caregivers to adequately plan for services in a way that the patient would prefer. Another is that NSHC has a variety of clinical services to offer, but that care is not always coordinated well unless the person experiencing dementia is admitted into Acute Care. Next is that the region does not have an in-home personal care service system large enough to meet the needs of the number of patients who require those services. Services are not available for all care needs, such as the lack of an Assisted Living facility or heavy chore assistance. The NSHC proposal would focus on developing a holistic and sustainable approach to offering care and resources to those in our region experiencing cognitive decline by increasing our regional awareness and recognition of dementia through providing culturally appropriate messaging about dementia and resources at community events and increasing training for NSHC staff to use standardized screening tools and consistently screen in village clinics and the emergency room. The proposal also outlines steps to increase our capability to make accurate and timely diagnoses through standardized evaluations and increased use of contracted Psychiatry staff for complex diagnosis. This standardized evaluation would include use of Multidisciplinary Team members that would also assess patient functionality, care needs, challenging behaviors, safety, caregiver support and more. The Team would also then meet for development of an interdisciplinary Plan of Care for the patient, incorporating caregiver feedback. That Care Plan would then be used to guide comprehensive case management and referral to other resources, including caregiver resources such as respite care. The grant will be used to fund staff to coordinate referrals of identified patients through assessment and then to resources for caregiving and other needs. That staff will also coordinate the meetings and documentation of the Multidisciplinary Team and work with regional Tribal and community services to expand collaborative care for patients. Resources and practices that are proven to be beneficial will be shared with other I.H.S. programs through the Alaska Native Tribal Health Consortium and other means. The Multidisciplinary Team will explore funding streams to support its work, including Medicaid and Medicare reimbursement for cognitive assessment and care planning, as well as using some corporation funds to do a pilot program for respite care.
