Although many community-based organizations offer supportive services for patients with dementia and their families, no comprehensive programs have existed to meet patients’ health needs and the needs of those around them. “Families need help with the everyday care, the daily problems experienced by people living with this disorder,” says David Reuben, M.D., chief of the Division of Geriatrics. Now there is assistance for those families. Earlier this year, the UCLA Alzheimer’s and Dementia Care Program was launched, with a mission to provide comprehensive, coordinated care, as well as resources and support to patients and their caregivers.
UCLA physicians can directly refer patients to the program, and all patients who are enrolled will be entered into a dementia registry. Program personnel will then contact patients in the registry to conduct a needs assessment of each patient, looking at medical, social and family needs and what resources are available to the family. Based on that assessment, an individualized care plan will be developed.
Care plans could include consultations with neurology, psychiatry and geriatrics staff; monitoring for disease progression and complications; participation in support groups; advanced-care planning, with consultations from the UCLA Ethics Center; hospitalization, when necessary, for medical, psychiatric or behavioral problems; referrals to appropriate clinical trials at UCLA’s Mary S. Easton Center for Alzheimer’s Disease Research; referrals, where appropriate, to community-based organizations for services; and in-home visits, if needed, for modifications of the patient’s physical home environment.
Each patient will also be assigned a nurse practitioner for intensive dementia-care management. The dementia-care manager, or someone covering for that individual during off hours, will be available 24 hours a day, seven days a week, for in-person and telephone assistance. Patients will still receive care from their primary-care physicians, who will be assisted by the program staff.
“This program isn’t so much about physician expertise,” says Dr. Reuben. “What we’re adding to the traditional care of dementia patients are the things that physicians haven’t had time to do or haven’t done well – coordinating care and ensuring that all of the family’s needs are addressed.”