Addressing Dementia in Tribal and Urban Communities-Enhancing Sustainable Models of Care - Indian Health Council, Inc. (IHC), a healthcare consortium of nine North San Diego County, California tribes, will enhance an integrated care model to address dementia affecting AI/AN seniors age 55+ and elders age 65 and over in its service area. Through its “Cognitive Health & Wellness Program,” launched in 2022, our approach aligns with the five primary Drivers identified by IHS that are integral to timely screening and patient care plan development and compliance, including support for caregivers. The program will address these areas: Awareness and Recognition. Training will be provided to front-line provider staff in the Medical and other departments in recognizing signs of dementia and screening tools (Mini-Cog, AD-8, and SLUMS). Culturally adapted education media will also be provided to the community to raise awareness through social media, videos, literature, and presentations at tribal and public meetings. This will include home visits and the importance of early detection, medications available, and local resources. A mobile health unit will be added to the program for home visits. Accurate and Timely Diagnosis. A key objective is to increase annual screening for individuals age 65+ as part of their Medicare Wellness Examinations. This will be achieved through improvements to client health records, scheduling, and tracking reports to the Cognitive Health & Wellness Nurse (CHWN), who will work with Medical and other departments to provide dementia screening during appointments. Interdisciplinary Assessment. An Interdisciplinary Care Team will review patient data to determine the need for more extensive evaluation, changes in medication, management of co-morbidities, in-home versus out-of-home placement, caregiver supports, and other issues related to assuring patient wellbeing is supported at each stage. Management and Referral. The CHWN in coordination with Patient PCP will assure patients with dementia, including those who have co-morbid medical conditions, receive appropriate levels of treatment during disease progression, and access to medical or other departmental services when needed. Referrals to outside specialists (e.g., neurology/radiology) will be supported through the referral department in addition to E-Consults. Support for Caregivers. Caregivers will be supported by: 1) In-home visits by the CHWN (and collaboration from other IHC staff) 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 the integrated care program model to share with other tribes/tribal health organizations, quarterly trainings to assure support for clinicians, and identification and implementation of funding streams to support service delivery and facilitate sustainability.
