Providing Comprehensive Care for Dementia Patients in Senior Living Communities by Dr. Carolyn Clevenger

The Integrated Memory Care Clinic (IMCC) is the only primary care practice in the United States that serves people living with dementia (PLWD) and their caregivers. This outpatient clinic has operated in the Atlanta area since 2015.

Given the progressive nature of dementia, it often becomes more and more difficult for caregivers to transport their people to a clinic and to manage their complex needs at home. Based on input from patients, families, and clinicians, IMCC leaders recognized the need to expand services beyond the clinic walls. By bringing the specialized and patient-centered approach directly to the people who need it, the innovative Integrated Memory Care in Community (IMCiC) program now provides high-quality, comprehensive care for residents with dementia diagnoses in select senior living communities. For more information on the program details and cost as well as to confirm partner communities, please call (404) 712-6929 or scan the QR code in our advertisement to complete an online interest form.

A groundbreaking care model

Structure, consistency, communication, and evidence-based interprofessional practice are essential to providing high-quality memory care.  The IMCiC multidisciplinary team, which includes a Nurse Practitioner and a Dementia Care Assistant (a community health worker with specialized training). The Dementia Care Assistant visits each patient weekly to provide support and primary care services. The team is also available for urgent needs.  If necessary, patients have access to a dedicated geriatric psychiatric Nurse Practitioner for behavioral and psychiatric symptoms not responsive to initial treatment.

But that’s only part of what makes IMCiC groundbreaking. Because there is immense pressure on those caring for a loved one, the project has also been designed with caregivers in mind. From the initial assessment to the detailed care plan, caregivers are included in every aspect of their person’s treatment. The team is in regular communication with caregivers, both scheduled and as needed.

Introducing residents and their caregivers

While patients may have very different treatment needs and experiences, the positive impacts of partnering with IMCiC are often surprisingly similar. This month and next, we will share the testimonial of a caregiver who has benefitted from the IMCiC program.

Vivian and her mom

Vivian’s mother was diagnosed with Alzheimer’s Disease (AD) in 2019 and has been living in an Assisted Living Facility (ALF) for a year and a half. Like many caregivers, Vivian initially experienced a number of “missteps” with her mother’s treatment, but was relieved to find IMCC and then IMCiC, which has been a “great fit.”

Vivian values the excellent care the IMCiC team gives her mother, particularly their provision of cognitive support, stimulation, and one-on-one time. After each weekly visit, Vivian gets a detailed summary of her mother’s daily activities, social engagement, nighttime behaviors, and overall mood. The report also contains specific goals based on these observations, and the following week Vivian’s mother engages in cognitive therapy and various other activities aimed at meeting those goals. “The level of auditory, tactile, and proprioceptive stimulation helps her so much,” Vivian says, and she adds that she has benefited from “reading through and incorporating their recommendations” into her own care behaviors for her mother.

Vivian echoes many other caregivers with loved ones in the IMCiC program when she expresses her amazement at how attentive the whole team is to her mother: “They know her habits and if they sense something is ‘off,’ they communicate with me, make a plan for medical assessment, and facilitate that care.” Beyond that, they are aware of the social and family events, and ask the person about these events. “Mom adores them,” she smiles, “and I feel like I have a team behind me!”

Providing excellent evidence-based care for people living with dementia requires frequent, clear communication. The IMCiC team structures its care around this principle, and caregivers have noticed it. Vivian stresses that IMCiC’s communications are unlike those of other programs-- staff are responsive, the online portal works very well, and she feels she could call on any member of her mother’s team “at the drop of a hat.” And though she recognizes that team members are busy, she reports that “they have really been available to me!” She gives a recent example that the NP on the team noticed that Vivian’s mother is slowing down slightly, and recommended Vivian have shorter visits, which could be more appropriate for her mother. “So,” she laughed, “I don’t only have nursing and medical assistance, I have a coach!”

After recounting the ways the IMCiC team has helped her mother, Vivian emphasizes that the support and guidance she has gotten from the team to balance her own work life, family life, and caregiving for her mother has also been enormously helpful. Vivian marvels at the many ways the program has “exceeded her expectations” of care for her mother and herself. She feels confident that as her mother’s dementia advances, she will be able to continue to seek assistance from the team members to navigate next stages, “So, please don’t take this program away!”

Learn more: www.nursing.emory.edu/imc

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