Weaving Pathways of Care aims to Improve the provision of culturally competent and age-friendly care, services, and outcomes for both Chickahominy citizens living with dementia and their caregivers. - Weaving Pathways of Care seeks to increase the provision of culturally competent and age-friendly care, services, and outcomes for both Chickahominy Tribal Citizens living with dementia and their caregivers, and to raise brain health awareness and cognitive screening rates among the Tribal Citizens. The Chickahominy Indian Tribe’s Leadership recognizes that American Indians experience cognitive impairment and dementia at higher rates than other racial and ethnic groups. They have an unwavering commitment to address this critical issue to improve the quality of life for both Tribal Citizens living with dementia and their caregivers, and to ease any burdens associated with resource and care navigation. While the Tribe currently provides brain health education and caregiver support, there is a need to increase provisions and create a robust system that encompasses a dedicated staff member along with aging services providers/agencies and healthcare providers. To do so, one key aspect of the project is to onboard a brain health navigator who will work specifically with both Tribal Citizens living with dementia and their caregivers. Some of the responsibilities of the navigator include providing brain health education, information about services offered via the newly-opened Mid-Atlantic Tribal Health Center (Indian Health Service), community agencies, and local health systems, and case management tracking. In order to have a comprehensive and HIPAA compliant tracking mechanism, the project will include implementing case management software. Forging new relationships and also building upon existing relationships with the Mid-Atlantic Tribal Health Center (Indian Health Service), community agencies, and local health systems are key components of the project. Through collaboration that includes education, training, and bi-directional referrals, the project will weave together an ecosystem that creates a strong path forward for culturally relevant and age-friendly care for both Tribal Citizens living with dementia and their caregivers. Expected outcomes of the project include, but are not limited to, increased knowledge and awareness of brain health risk factors and dementia signs and symptoms, increased number of cognitive screenings, and increased assessments for social needs and improved access to resources to address identified needs. Moreover, the project is expected to help demystify the process of obtaining cognitive screenings and associated services if a positive screen occurs. Through culturally appropriate, thoughtful, and concerted efforts, the project will lift up and support our most vulnerable population. Initial project implementation followed by future growth will provide immeasurable value for the next seven generations.
