Providing Comprehensive Care for Dementia Patients in Senior Living Communities by Dr. Carolyn Clevenger, Emory Integrated Memory Care

The Integrated Memory Care Clinic (IMC Clinic) 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, IMC Clinic 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 (IMC Community program) 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 visit https://www.nursing.emory.edu/imc 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 IMC Community program
multidisciplinary team 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 the IMC Community program 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 the IMC Community program are often surprisingly similar. Last month, we
shared the testimonial of a caregiver, Vivian. This month, we highlight the story of Kate and her
mother who have also benefitted from the IMC Community program.

Kate and her mom

Kate’s mother has Lewy Body Dementia (LBD) and started showing signs of dementia around
the time the pandemic started. At that time, Kate contacted IMC Clinic and began the process of
discussing appropriate care for her mother. Initially, the family placed their person at an assisted living facility (ALF) but continued receiving care at the IMC Clinic location. Eventually, Kate
enrolled her mother in the IMC Community program.

Kate admits she had some reservations when it came time to transition her mother into the IMC
Community program. “At that point I had such a good relationship with [the Nurse Practitioner
at Clinic], that I was a little reluctant to transition into the community program,” fearing she
would be “upsetting the apple cart.” However, she has found that “the in-community program
and the alliance with the facility is remarkable.”

Kate describes a major change in her mother’s “outlook” when she began working with the IMC
Community program team. Before enrolling in the program, her mother had been frustrated with
the “revolving door” of staff at the facility. Since Kate is so hands-on with her mother’s care, she
found herself spending a lot of time coaching staff at the facility on how to approach her mother,
whose disease (Lewy Body Dementia) is very different from Alzheimer’s Disease. Once the
IMC Community program team arrived, they understood the disease so well that they were able
to advocate for the patient with the other staff at the facility. This has had three positive
outcomes: 1) taking pressure off Kate so she was no longer running constant interference for her
mother; 2) making use of the IMC Community program teams’ interprofessional skills to
communicate with the facility staff; and 3) decreasing her mother’s agitation.

Kate expresses particular delight with the Dementia Care Assistant (DCA) on the team, who
“meets my mom where she is.” The DCA recently set up a scavenger hunt for her mother, who
“had the BEST day” doing that activity. She notices that the DCA is in tune with how much
energy her mother has and paces their time together accordingly. She knows “when to push and
when to ... call it quits.” The DCA has very quickly become attuned to her mother, and, says
Kate, “that has been a highlight—an absolute highlight.” She adds, “everyone on the team is
meeting regularly. So, even though [certain team members] are not assigned to her, they know
who she is, they know what’s going on with her, and they know how to interact with her.”

Kate has just begun assisting her mother to transition to Hospice care. She is truly grateful for the
IMC team.

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

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