MaineHealth’s Alzheimer’s Disease Partnership: Expanding Dementia Capability in a Rural and an Urban Setting

Presented by: Mary Jane Krebs, RN, MA, FACHE

October 17, 2019

• Predominantly rural state – 1.3m people

• Oldest state – median age 44.7 years

• Largest proportion of people 65 years (20.6%)

• In 2020, individuals 65 years will outnumber those 19 years (15 years ahead of

national projected date of 2035)

• By 2030, 28% of Maine’s population will be 65 – higher than any other state. National

estimate 20%

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About Maine

• Northern New England’s largest

not-for-profit integrated healthcare

system serving 1.1 M residents in 12

Maine and NH counties

• Committed to supporting healthy

individuals and healthy

communities; provides care for all

regardless of ability to pay

• Members work closely together to

identify and

share best practices and resources

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About MaineHealth

The 4M’s

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• Becoming an Age Friendly Healthsystem (AFHS) entails providing a set of evidenced

based, geriatric best practice interventions across four core elements known as the 4M’s.

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Moving Towards an Age- Friendly Healthsystem

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Healthcare & CBO Connection

2000•MaineHealth Partnership for Healthy Aging Created (MH & SMAA)

2003•Chronic Disease Self Management Program (MH, SMAA & PHO)

2003 –2006

•A Matter of Balance translational grant (PFHA, MMC, USM & SMAA, SG dissemination site)

2006•N4A Aging Innovations and Achievement Award (SMAA, MH)

2006 –2011

•Choices for Independence AoA grant to Maine (PFHA administers, SMAA, SG dissemination sites)

2008•Community Links (SMAA, MH w/Providers)

2010•Aging & Disability Resource Center-Care Transitions Intervention Collaborative (SMAA, PHO/MHACO, & MH)

2012•Community-based Care Transitions Program (SMAA, SG, PHO & MH)

2013:

•Advance Care Planning (SMAA, MH, MHACO)

•MSSP ACO designation MHACO

2015•MHACO Shared Savings With SMAA, SG

2016

•ACL CDSME Award SG

•ACL Fall Prevention Award SMAA

•MHACO and MH nominate SMAA CEO for John A. Hartford Business Foundation Award

2017• MHACO Grant Award to SMAA for ACP with PCP

• ACL Dementia Capability Grant (MH, USM, SMAA, SG, and Alzheimer's Association

Southern Maine Agency on Aging (SMAA) serves Maine’s two most southern counties,

Cumberland and York - 34% of total population, 31% of those 65 years.

2014-2017 awarded over a $900,000 US DHHS Administration for Community Living Grant

for their Alzheimer’s Disease initiative.

FOCUS: expand a robust foundation of dementia capable services to provide a more

comprehensive, sustainable network of training, referral and person-centered

services for people with advanced dementia and caregivers of those with dementia.

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About Southern Maine Agency on Aging

• Complex Case Management Community Support Program developed for people living

alone with dementia.

• Expanded Meals on Wheels (MOW) assessment screening for memory loss.

• Referrals for comprehensive assessment.

• ADS Plus evidence based training and counseling for caregivers.

• Identification of who was connected to the person with dementia (CM, first responder,

SMAA, neighbor) collaborate to provide wrap-around services.

• Developed trainings on dementia, intellectual disabilities and dementia, adult day

savvy skills and provided these to MOW volunteers, SMAA employees and

volunteers, adult day service staff.

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Results

• Lack of both dementia awareness and capability training persists within the community and among

professional providers.

• Serving people with dementia who are living alone requires time and patience to build trust, understand

their needs, and develop a support system. Helpers must be willing to do things differently, rather than

trying to hustle the person along or shortcut the process.

• Persons in earlier stages of dementia are often reluctant to accept assistance.

• Systemic barriers are worse for people with dementia.

• A team approach including all involved is the most effective strategy for improving client interventions and

outcomes.

• Developing volunteer support for people with dementia requires a higher level of training, monitoring,

and ongoing support than for other volunteer programs serving older adults.

• Adopting evidence-based interventions requires flexibility and top-down support.

• To be sustainable, interventions must be normalized into everyday practice.

• One size does not fit all. Caregivers’ needs change over time and, thus, are best met with a flexible menu of

services and supports.

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Lessons Learned

• Dementia is “an acquired syndrome of decline in at least two cognitive domains,

sufficient to affect daily life in an alert patient.” 1

• While many physicians screen for cognitive impairment for patients with family history or

early signs of Alzheimer’s disease, only 56% regularly screen asymptomatic patients

over age 65.2

• Early identification of dementia is important because it lowers the risk of premature

institutionalization.3

• A 2018 survey of 52 MH physicians and APPs found that respondents who had

dementia specific training were more confident in their ability to diagnose dementia,

provide information about the diagnosis, and refer patients to specialists for further

evaluation. (Internal program evaluation)

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Background Literature

Sources: 1. Threlfall A.W. , Barton C., and Yaffee K. (2013) 2. Stewart et al. (2014) 3. Barnett et al. (2014).

• In 2012, 37,000+ people in Maine were diagnosed with some form of dementia and the

number is expected to increase to 53,000 by 20201 .

• In Maine, an estimated 230,000 family caregivers provide most care for persons with

Alzheimer’s Disease and Related Disorders (ADRD) in the home2.

• These caregivers try to do this on their own without formal or informal support.

Findings show a decline in emotional, mental and physical health often arise from

strain of caregiving.

• The number of workers is not growing at the same pace – creating a critical need for a

dementia-capable workforce3.

• Healthcare organizations cannot address all of the supportive needs of patients and

caregivers alone. Partnerships with Community-Based Organizations (CBO) is

critical.

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Dementia Care in Maine: Current State

Sources: 1. 2012 State Plan for Alzheimer’s Disease and Related Dementias 2. Building Collaborative Community

Response to Aging in Place (2013) 3. Maine’s State Plan on Aging 2016-2020

• MaineHealth (MH) received a US DHHS Administration for Community Living Grant in

September, 2017 for their Alzheimer’s Disease Partnership initiative.

• Direct service began in April 2018, following a six-month planning period.

• The project has two geographic areas: Greater Portland (urban) and Lincoln County

(rural).

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Project Overview

Southern Maine Area on Aging (SMAA)

Maine Medical Center (MMC) Geriatrics Center

MMC Center for Outcomes Research and Evaluation (CORE)

MaineHealth Accountable Care Organization

Maine Behavioral Healthcare

Miles and St. Andrews Home Health and Hospice

Alzheimer's Association of Maine

Community Paramedicine

Spectrum Generations Central Area Agency on Aging

University of Southern Maine

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Partners

Three year project aims to expand MaineHealth's dementia capability by:

1. Strengthening dementia specific training for community-based service

providers and healthcare professionals.

2. Expanding existing services, introducing new evidence-based

programming, and working to improve connections between the health

system and the community based organizations.

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Project Aim

1. Training: Deliver dementia-specific training to CBO and healthcare team members

2. Direct Service: Provide effective care and supportive services to persons living alone

with mild to moderate ADRD and persons with moderate to severe ADRD living with their

care partners.

3. Increase healthcare and community connections: via referrals between

healthcare system and CBOs

4. Explore the Medicare Annual Wellness Visit (AWV) as a potential pathway to

care.

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Project Objectives

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Healthcare

Urban CBOs

Rural CBOs

Training Model

1. Medical Assistant in Primary Care (goal: 200)

a. Direct training on administering the Mini-Cog

2. MHACO Nurse Care Manager (goal: 230)

a. Training modules spread over various training days regarding dementia and delirium from Heidi

Wierman, M.D. and Tammy Vachon, LCSW

b. Topics to include: recognizing symptoms, symptom management, working with patients in their

homes and communities.

3. Maine Behavioral Healthcare-BHI clinicians (goal:48)*

a. One day training focused on the clinical aspects of working with patients with dementia and their

care partners

b. Training will focus on working with care partners to provide therapeutic support, psycho-

education and referrals to community resources

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Training: Healthcare

• Your Role in Dementia Detection and Treatment by MMC’s Dr. Sarah Hallen1 (online:

https://www.youtube.com/watch?v=lt0rioR_g-

U&index=3&list=PLdUh18gUQ0NPUu_uwl6L9go29o_ESlD3V)

• Teepa Snow: Positive Physical Approach Workshop (2019 MMC Geriatrics Day)

• Annual MMC Geriatrics Day

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Training: Healthcare Cont.

1. HRSA Geriatric Academic Career Awardee grant ##K01HP20461

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Training: CBO’s in the Urban Setting:

• Teepa Snow Positive Approaches to Care for all direct care staff (27-SMAA)

(including Adult Day Service and community resource specialist staff)

• Music & Memory©

• Train three Mainly Delivered Meals assessors to use the “More than a Meal Screening and

Referral tool”

• CARES© training for 6 personal support specialists in Lincoln County

• Alzheimer’s Association’s First Responders online training

• Alzheimer’s Association’s “Communication Strategies” and “Difficult Behaviors” train

the trainer for CBO’s

• Music & Memory© training

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Training: CBO’s in the Rural Setting:

• Resources for Enhancing Alzheimer’s Caregiver Health (REACH)Community™

• Music and Memory©

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Evidence-based Services

• REACH stands for Resources for Enhancing Alzheimer’s Caregiver Health.

• REACH Community™ is an evidence-based intervention for caregivers of persons with

dementia focused on information, safety, caregiver health and emotional well-being and

patient behavior management.

• Targeted Participants: People caring for individuals with dementia

• Length of Sessions: 1 hour

• Length of treatment: 2-4 months

• Number of sessions: up to 5 sessions (minimum of 4) in person and by phone

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REACH Community™

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Music and Memory© An evidence-informed intervention shown to reduce agitation and anxiety among people

with ADRD by listening to personalized music playlists

Lincoln County: SG

• Target Population: Current or new

clients that are assessed to have

mild to moderate dementia and

have an identified caregiver.

• Intervention location: in the home

Greater Portland: SMAA

• Target Population: Current or

new clients that are assessed to

have mild to moderate dementia.

• Intervention location: In the

adult day center (Biddeford),

during program hours

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Expand Existing Services

LINCOLN COUNTY:

SPECTRUM GENERATIONS (SG)

GREATER PORTLAND:

SOUTHERN MAINE AGENCY

ON AGING (SMAA)

• Community Resource Support Service (CSP)

• Personal Support Service (PSS)

• Mainely Delivered Meals (subsidized meals)

• Alzheimer specific Community Education Sessions

• Community Supports

Program (CSP)

• Adult Day Scholarships

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• Training of healthcare and CBO professionals

• Identifying individuals with dementia (AWV and CBO screening)

• Referrals between health system and CBOs

• Evidence-based programming

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MaineHealth’s Dementia Capability: Baseline

Training:

• Alzheimer’s Disease Knowledge Scale (ADKS)

• Teepa Snow Training Pre/post test

• Six-month practice change survey

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Measures

Service Delivery:

• REACH Community™: Caregiver Risk Assessment Tool

• Music and Memory©

- Care Partner: Zarit Burden Inventory 12-item (ZBI-12)

• Community-based direct services: Well-being Assessment Scale

(WBAS)

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Measures

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Training: Who

Healthcare Professionals

• Medical Assistants

• ACO Nurse Care Managers

• BHI clinicians

• REACH Community TM

Community Based Organizations

• Teepa Snow

• “More than a Meal “Expanded

Assessment

• CARES©

• Alzheimer’s Association train the trainer

• Music and Memory©

• First Responders Training

Behavioral Health Clinicians (N=48)

ADKS Pre-Post Test results:

• The number of individuals scoring 90% or better increased from 43% to 70% following

the training.

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Preliminary Training Outcomes

Community Partners Teams (N=41)

ADKS Pre-Post Test results:

• The number of individuals scoring 90% or better increased from 51% to 68% following

the training.

6-month practice change results:

• 78% response rate

• 90% of respondents reported having a better understanding of Alzheimer’s disease and

being more confident in carrying out their responsibilities working with individuals with

Alzheimer’s disease.

• 63% reported feeling more comfortable asking caregivers about their health and quality

of life as a caregiver.

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Preliminary Training Outcomes

• Referral barrier in the rural setting

• Training Paramedicine

• Workforce Issues (Hiring, Turnover, Demographic Change)

• Relationship Development between Healthcare and CBO

• Consumer Experience

• Access to services and practice workflows

• Evaluation Tools

• Education about service delivery and availability

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Lessons Learned

• eHR based referrals and feedback loop (e.g. Aunt Bertha)

• Increase the number of people accessing and using programming

• Train more Internal and Family Medicine integrated clinicians

• Expand coverage areas to Western Maine, PenBay and Waldo

• Increase capability in MMP

• Bill for intervention using 90846 code where applicable

• Continue to learn – Seniors Plus (Oxford, Franklin and Androscoggin Counties) awarded

the next 3 year ACH grant to continue this work

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Next Steps

Questions?