Norton Sound Health Corporation's Addressing Dementia in the Bering Straits Region of Alaska - The Norton Sound Health Corporation (NSHC) proposes to continue to develop an increased clinical capacity to coordinate thorough and timely services for those experiencing cognitive impairment because of 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 a 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. As a 2023 grantee of the Indian Health Services “Addressing Dementia in Indian Country: Models of Care” grant, NSHC has made considerable progress towards developing a holistic and sustainable approach to offering care and resources to those in our region who are experiencing cognitive impairments. However, we recognize that we continue to have service gaps that we propose to address under this grant. The first is early recognition of dementia, to allow those patients and caregivers time 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 well coordinated 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 regionally for all care needs, as we lack an Assisted Living facility and heavy chore assistance. The NSHC proposed grant activities will focus on implementing best practices as outlined in the CDC/Alzheimer’s Association’s “Healthy Brain Initiative Road Map for American Indian and Alaska Native Peoples” through providing culturally appropriate messaging about dementia and resources at community events, increasing training for NSHC staff to use standardized screening tools, and an emphasis on consistently screening patients in outpatient and inpatient settings, including village clinics. The proposal also outlines steps to increase our capability to make accurate and timely diagnoses through standardized evaluations and increased use of Psychiatry/Psychology staff for complex diagnosis. This standardized evaluation would include continued use of an established Multidisciplinary Team to assess patient functionality, care needs, challenging behaviors, safety, caregiver support and more, and then develop patient centered Care Plans with caregiver feedback. The Care Plan would be used to guide comprehensive case management and referral to other resources, including caregiver resources such as respite care, support services and education. Quality of Life measures will be utilized to inform patient and caregiver support activities. The grant will be used to continue to fund staff, including a full-time Referral Coordinator position. This position will coordinate referrals of identified patients through comprehensive assessment and facilitate access to resources for caregiving and other needs. That staff will also 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 pursue funding streams to support sustainability, including expanding billing for Medicaid and Medicare reimbursement for cognitive assessment and care planning. NSHC will also use some limited NSHC funds to provide respite care for those patients who are
