Enhancing Dementia Care for Urban Native Elders: A Sustainable, Person-Centered Model at OKCIC - Oklahoma City Indian Clinic (OKCIC), a federally qualified Urban Indian Health Organization, proposes to implement a culturally sensitive, comprehensive dementia care program tailored to the needs of American Indian and Alaska Native (AI/AN) elders. The purpose of this project is to improve early identification, interdisciplinary care, and caregiver support for patients living with dementia through the integration of evidence-based frameworks, including the Age-Friendly Health Systems 4Ms (What Matters, Medication, Mentation, and Mobility). This project builds on existing clinic workflows, including cognitive screening and caregiver support, and expands them into a sustainable model of dementia care. Activities will include distributing patient education materials, expanding dementia screening and diagnostic protocols, implementing interdisciplinary dementia assessments to increase diagnostic accuracy, developing person-centered care plans, improving referral coordination, and offering structured caregiver education and resources. OKCIC will also partner with the Alzheimer’s Association and the Oklahoma Foundation for Medical Quality to support these efforts and further build community partner relationships. The program will be continuously evaluated using both process and outcome measures. Screening rates, care plan completion, caregiver training participation, and patient satisfaction will be tracked. Findings will be reviewed quarterly, and the model will be refined throughout the grant period based on data and patient feedback. Expected outcomes include increased access to dementia screening, improved accuracy and timeliness of diagnosis, expanded access to interdisciplinary care coordination, and strengthened support for caregivers. Ultimately, this initiative aims to reduce health disparities, improve quality of life, and serve as a national model for dementia care in Native communities.
