![Page 1: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/1.jpg)
Dementia and Primary Care
A Structured Team Approach
UNE/MGEC Conference
June 2014
![Page 2: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/2.jpg)
First Proviso
• I have no actual or potential conflict of interest in relation to this program or presentation.
![Page 3: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/3.jpg)
Second Proviso
• There is a great deal of experience in caring for older adults in this room
• Although I focus time, reading and thinking on geriatric issues, at the end of the day there is a great deal of judgment involved and we learn from each other.
![Page 4: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/4.jpg)
Maine organizations for Health Professionals
• AMDA
• MGS
• DGS
![Page 5: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/5.jpg)
Audience role in caring for Older Adults with Memory Impairment
• PCS’s
![Page 6: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/6.jpg)
Audience role in caring for Older Adults with Memory Impairment
• PCS’s
• Other Community based providers
![Page 7: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/7.jpg)
Audience role in caring for Older Adults with Memory Impairment
• PCS’s
• Other Community based providers
• LTC or other facilities
![Page 8: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/8.jpg)
Audience role in caring for Older Adults with Memory Impairment
• PCS’s
• Other Community based providers
• LTC or other facilities
• Students
• Other disciplines
![Page 9: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/9.jpg)
GOALS Structured Team Approach
• Keep it simple • Team
– Maximize the resources you have
• Structure (measures) – ACOVE – Roadmap
• Q/I – Pick simple projects which will work with the tools
you have – This is for Q/I not publication
![Page 10: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/10.jpg)
Quality Improvement
Quality Improvement
Patient encounter
![Page 11: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/11.jpg)
Who will provide Dementia Care?
• 7,000 Boarded Geriatricians in the US
• 12,000 Neurologists
• 2,500 Geriatric psychiatrists
• 222,000 Primary Care Specialists
– Provide 80% chronic care for older Americans
Xakellis GC. J Am Board Fam Pract. 2004
Grumbach JAMA 2002
![Page 12: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/12.jpg)
Who will provide Dementia Care?
• Cancer or CHF?
• There are parts of this work that can ONLY BE DONE BY A PRIMARY CARE SPECIALIST
![Page 13: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/13.jpg)
Fundamental Concept of Geriatric Care
•FUNCTION
![Page 14: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/14.jpg)
Medicare Current Beneficiary Survey
• “functional status is a more important predictor of death and functional decline than are specific clinical conditions.”
![Page 15: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/15.jpg)
The Challenge
• Chronic illnesses
• Geriatric syndromes
• Social Issues
• ALL IMPORTANT IN MAINTAINING
FUNCTION
![Page 16: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/16.jpg)
Chronic Disease Management in the Elderly
![Page 17: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/17.jpg)
Chronic Disease Management in the Elderly
• Multiple Medical Conditions
• Multiple ‘Quality Indicators’
– Little research on these metrics in Vulnerable Elderly or people with multiple comorbidities.
• Have significant functional impacts
– Under treatment
– Over treatment
![Page 18: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/18.jpg)
AGS initiative “3 or more” (3+)
• Introduced at AGS meeting May 2012
• Over 50% of older adults have 3 or more chronic conditions
• Almost all existing ‘guidelines’ have single disease focus
• Initiative is to develop guiding principles for the management of the older adult with comorbid conditions.
AGS Expert Panel J Am Geriat Soc 60:1957-1968,2012
![Page 19: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/19.jpg)
(3+ = 6+)
• The reality is even more complex
– VA study looking at common combinations of 3 CI’s.
– In patients with the 15 most common triplets the mean number of conditions ranged from 6.7-8.5.
– J Am Geriatr Soc 60:1872-1880,2012
![Page 20: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/20.jpg)
Geriatric Syndromes
![Page 21: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/21.jpg)
Geriatric Syndromes
• Common syndromes in older persons
• Often Multifactorial in cause
• IMPAIR FUNCTION
• Increase Caregiver Stress
• Increase risk of institutionalization
• Are under treated
• Often travel in tandem
![Page 22: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/22.jpg)
GERIATRIC SYNDROMES
• Memory Impairment
• Falls and Gait Impairment
• Urinary Incontinence
• Delirium
• Sleep Problems
• Polypharmacy
• Elder Mistreatment
• Frailty
![Page 23: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/23.jpg)
Complexity of an Office Visit
• 3+ - 6+ Chronic Illnesses
• Geriatric Syndromes
• Social Issues
![Page 24: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/24.jpg)
Structured Team Approach
![Page 25: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/25.jpg)
TEAM
• Effective integration of all
• This is a big job.
![Page 26: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/26.jpg)
TEAM
• The team we need extends well beyond the clinician’s office.
• Only a small amount of the care of a memory impaired older adult occurs in the office
• The office DOES NOT play the most important role in the individual’s care.
![Page 27: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/27.jpg)
Community resources
Person’s Support system
Office Team
Team in Geriatrics
![Page 28: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/28.jpg)
Office Based Team
Medical Records
• Chart Prep
• Maintain reminders
Secretary
• Observations of pt that may be clinically significant
MA
• Observations of pt
• Mini-cog
Physician
• Basic initial evaluation
• Set up visit with PA
• Dx/management
• Leadership
PA
• Template-based visits for Geriatric Syndromes based on ACOVE
• Participate in dx/management
![Page 29: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/29.jpg)
Team involved in Care & Q/I
Care &
Quality Improvement
Physician
MA
PA
Secretary
Medical Records
![Page 30: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/30.jpg)
Other Format
• Can do as single provider
– Multiple visits
– Weave pieces into other visits using reminder system and flow sheet
• Cancer model
– Recognize
– Refer
![Page 31: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/31.jpg)
STRUCTURE
• Key to implementation of standardization
– Allows measurement for Q/I
• There are no geriatric specific CMS indicators.
• ACOVE
![Page 32: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/32.jpg)
ACOVE
• Assessing Care of the Vulnerable Elderly
– Series of indicators of care for vulnerable elderly patients we should all meet. • In reality aspirational
– 17 indicators for dementia – I will reference in this talk as used to develop office
based approach. Wenger et al. J Am Geriat Soc 55:S247-S252,2007
![Page 33: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/33.jpg)
ACOVE
• Literature references available on the Rand web site
• Tools available at UCLA
– http://www.geronet.ucla.edu/professionals/patient-care-resources
![Page 34: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/34.jpg)
Comprehensive Roadmap
Referenced by Dr. Singer
![Page 35: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/35.jpg)
Our Practice
• Our checklist
• Screening
• Diagnosis
• Management
• Follow up
![Page 36: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/36.jpg)
Screening
![Page 37: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/37.jpg)
Screening
• Should we screen?
![Page 38: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/38.jpg)
Screening
• Should we screen?
• Who has a structured approach to screening?
![Page 39: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/39.jpg)
WHY SCREEN?
![Page 40: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/40.jpg)
Why screen
• Under diagnosed
– 30-50% of people with MI are not diagnosed
– Case finding only picks up 20% of cases identified by screening.
– Variability
• Our Q/I
– 6-63% MI in all patients >75 y/o
![Page 41: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/41.jpg)
ACOVE for Dementia
• IF a VE is new to a practice or inpatient service, THEN there should be a documented assessment of cognitive ability and functional status.
![Page 42: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/42.jpg)
How we screen
• Case finding – Team
• Patient • Any one on my office team • Caregiver
– Informant interview (AD8)
• Concerned others
• Screen (structure) • AWV • All > 75 (prevalence 11% 75-84 y/o)
– From the Q/I showing the differences
• Falls
![Page 43: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/43.jpg)
Screening tool
• Mini-cog
– MA
– Dr. Singer’s talk
![Page 44: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/44.jpg)
Mini-cog: Scoring
• Dr. Singer’s talk algorithm
• Five point score
– 0-3 for recall
– 0 or 2 for clock
• Numbers in correct order and hands correct
– 4-5 normal
– 0-2 abnormal
– 3???
– Difficulty drawing the circle ???
![Page 45: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/45.jpg)
Mini-cog as a screen
• Goal is to start down a path so looking for high sensitivity
• Research needs to be tight
• Clinical Medicine is curiosity about the patient in front of you.
![Page 46: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/46.jpg)
Screening tool
• Functional Evaluation
– IADL
– VES 13
![Page 47: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/47.jpg)
IADL’s
• Phone
• Shopping
• Food Preparation
• Housekeeping
• Laundry
• Transportation
• Medication Management
• Financial Management
![Page 48: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/48.jpg)
VES-13
• Age • Self rated health • Functional assessment
– ADLs and IADLs
• Note: No use of disease burden – Depends on Functional impairment being the final
common pathway. Journal of the American Geriatric Society.
2001;49:1691-9.
![Page 49: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/49.jpg)
Diagnosis
![Page 50: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/50.jpg)
ACOVE for Dementia
• IF a VE screens positive for dementia, THEN a physician should document an objective cognitive evaluation that tests two or more cognitive domains.
![Page 51: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/51.jpg)
Dementia
It is not dementia without new significant functional impairment due to the cognitive impairment
![Page 52: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/52.jpg)
Diagnosis: Tools
• MoCA
• MMSE
– Well known, high specificity for mild AD, high level of literature support
– Not in public domain
• AD8
![Page 53: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/53.jpg)
Diagnosis
• 3 D’s
– Dr. Singer has addressed
• 3 D’s + 2P’s
• 2 P’s Poly Pharmacy
– CNS active drugs
– Anticholinergic medications
![Page 54: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/54.jpg)
Diagnosis
• First Level – Normal – Normal MSE but concerns – MCI – Dementia
• Second level – SDAT – Vascular – Lewy body – Parkinson – Other
![Page 55: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/55.jpg)
Our Practice-Team
• Screen or history raises concerns
• PA template visit – See specific Visit #1 for goals of that visit (WIP)
• History – Template
• MSE – MMSE
– MoCA
• PE
• Med review
• Further workup
![Page 56: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/56.jpg)
Patient Encounter: Prep and Visit
Medical Records
• Chart Prep
• Maintain reminders
Secretary
• Observations of pt that may be clinically significant
MA
• Observations of pt
• Mini-cog
Physician
• Basic initial evaluation
• Set up visit with PA
• Dx/management
• Leadership
PA
• Template-based visits for Geriatric Syndromes based on ACOVE
• Participate in dx/management
![Page 57: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/57.jpg)
Our Practice-Q/I
• Very quickly saw that we were not meeting all the elements we wished to as delineated by ACOVE
• 2 visit approach
• Developed flow sheet
– Under using as requires extra steps in EMR
• Assigning more to medical records
![Page 58: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/58.jpg)
Management
• Medication
– Dr. Singer’s talk
• 65% use of cognitive enhancing medications in community based patients. (JAGS 61:723-733, 2013)
– 2 P’s Poly Pharmacy
• Really PCS issue
– WHO ELSE IS GOING TO PRIORITIZE AND COORDINATE ALL OF THIS?
• Beer’s list
– Anticholinergic medications
– CNS active medications
![Page 59: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/59.jpg)
Management
• Much more than medication
– Again reference the checklist
– Medical illnesses
• MANAGE TO MAXIMIZE FUNCTION
– Patient and caregiver resources
– Connect to community resources
– Legal issues
• Competency
– Driving
![Page 60: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/60.jpg)
Management-Team
• This work in the office is shared between Physician and PA.
– Communication
– Flow sheet
![Page 61: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/61.jpg)
Management-Q/I
• Early recognition that we were not routinely connecting with community resources
– Pamphlet from our AAA
![Page 62: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/62.jpg)
Follow-up
• This is the ‘third side of the coin’.
• We have not standardized our approach – MS
– Function
– Behaviors
– Caregiver stress • Can not overemphasis this
• Flow sheet really helps
![Page 63: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/63.jpg)
And then
• 80% of chronic care older adults will continue to be provided by PCS’s
• A Structured Team approach
• Refer when you need help
– Geriatrician/Neurologist/Geriatric Psychiatrist
![Page 64: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/64.jpg)
MEDCAPS
• Grant to the OADS
• Make Maine Dementia Capable
• Broad reach
• Focus on physician practices
– ACOVE and other indicators
– CME session
– Recruit practices interested in Q/I
• A-Q/I for MOC
![Page 65: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/65.jpg)
Discussion
![Page 66: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/66.jpg)
Team structure and roles
• Medical Records – Chart prep
– Maintain reminders
– Input on process
• Secretary – Observations on patients that may have
clinical significance
– Input on process
![Page 67: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/67.jpg)
Team structure and roles
• MA – Observations on patients
– Mini Cog
– Q/I
– Input on process
• PA – Template based visits for Geriatric Syndromes based
on ACOVE
– Full participation in diagnosis and management
– Input on process
![Page 68: Dementia and Primary Care - University of Ne and Primary Care V2.2... · Dementia and Primary Care ... •Multiple ‘Quality Indicators’ –Little research on these metrics in](https://reader034.vdocuments.us/reader034/viewer/2022051718/5a70d60c7f8b9a9d538c5b15/html5/thumbnails/68.jpg)
Team structure and roles
• Physician – Recognition and very basic initial eval
– Set up visit with PA
– Full participation in diagnosis and management
– Input on process
– Leadership