TCRHCC Dementia Program - TCRHCC is a nonprofit, tribal 638 organization in Coconino County, Arizona, and is the sole health care provider in this region of over 33,000 Navajo, Hopi and San Juan Southern Paiutes. While TCRHCC Neurology department currently provides a variety of dementia-related care, there is work to be done in building community-clinical linkages, increasing community awareness, supporting caregivers, and enhancing primary care providers’ capacity to screen patients for dementia. TCRHCC is an ideal candidate for this grant to establish a comprehensive Dementia Program for American Indians because it has the capacity for not only outreach and education, but also screening and treatment, all within one system. A Dementia Program aligns with TCRHCC’s mission to “provide safe, accessible, quality and culturally sensitive healthcare.” TCRHCC already provides ambulatory care to patients living with dementia, but is requesting this funding to establish a formal Dementia Program. The goal of creating a Dementia Program is to improve coordination of care, culturally relevant services, and ultimately health outcomes for American Indian individuals living with dementia and their caregivers within the Tuba City Service Area. Through enhancements in each of the five primary drivers, TCRHCC will build a more comprehensive, person-centered model of dementia care. In particular, TCRHCC will: • Raise awareness of dementia through creation and distribution of culturally-relevant community educational materials and outreach campaigns, as well as training TCRHCC staff to recognize early signs of dementia. • Increase the number of patients screened for dementia during routine health assessments by identifying and addressing current barriers, implementing system-wide policies, and implementation of standardized screening tools. • Increase the number of patients who receive an interdisciplinary assessment and associated care referrals - enhancing coordination of care through formalizing internal department collaboration, creating an interdisciplinary assessment tool and care plan documents, and documenting standard processes. • Decrease the use of crisis-driven care (ER visits and hospitalizations) among patients living with dementia by providing comprehensive, person-centered Management and Referral to meet needs. A major focus of the grant activities will be to improve community-clinical linkages by building a network of community-based resources. A dedicated Dementia Program Case Manager will facilitate referrals to community services and follow up to ensure dementia patients and their families successfully receive the services needed. Existing dementia treatment programs will be enhanced, and processes implemented to track patients’ course of dementia. • Support caregivers through identification/creation and distribution of culturally-relevant caregiver educational materials, implementing educational telehealth visits for caregivers to overcome barriers, identification/creation of a caregiver peer support group, and training providers to more effectively communicate with caregivers.
