1. Model for Collaborative Care Using a Care Navigation Team to Provide Enhanced Psychosocial Support Services at the Brain Health Center at California Pacific Medical Center (CPMC) in San Francisco, California.
Nalani Griffin Dunn, MSW/LCSW; Catherine Madison, MD; Ymke Dioquino, MS/MFTI; Howard Hahn, MSW Intern
Department of Neurosciences; California Pacific Medical Center, San Francisco, CA, USA
Care Navigation follow up within 2-3 weeks, case management assistance, emotional support, connection to Alzheimer Association and community resource referrals
Education & on-going emotional support regarding diagnosis, group and individual therapy referrals
Medical provider evaluation and recommendations
Background
Conclusions
Solution
 Alzheimer’s Disease (AD) the most prevalent form of all the dementias, is the 6th leading cause of death and there is no cure. Symptoms affect each person individually, ranging from mild short-term memory loss, confusion, irritability and aggression, mood swings, language difficulties, long-term memory loss to total disability.
Ultimately, the person will come to rely completely on a caregiver(s) typically a spouse and/or adult child, usually a daughter, to provide care in all aspects of daily life.
The emotional, physical and financial impact on caregivers, extended family, communities and humanity is profound and exponential. Persons with AD may have had the disease for many years without vital medical and psychosocial intervention often due to the fear of diagnosis and the associated stigma. Often patients and their families come in for care when they are already exhausted and in crisis.
In 2012 the Memory Clinic at CPMC expanded it’s services to become the Brain Health Center (BHC) at CPMC, made possible by a generous endowment. The mission of the is BHC is to help persons preserve cognitive strength and deal positively with changes to maintain independence and harmony, by providing leading-edge diagnosis, treatment, research, assistive technology and psychosocial support.
The BHC partners closely with the Alzheimer’s Association to reduce stigma, provide education and increase awareness of AD and all the dementias and to support brain health.
In 1990 Harold P. Freeman created the patient navigation concept to eliminate barriers to patient cancer care, to increase timely diagnosis and treatment, which has successfully reduced mortality. The model has expanded to provide support to patients with chronic and life threatening illnesses, as they move through the medical care system of prevention, diagnosis, treatment and supportive end of life care.
This model creates enhanced communication between medical providers, the care navigation team and the patients/families served. This allows for the medical treatment and psychosocial support to be continuously adjusted in order to optimally meet the changing needs of each individual/family in this at-risk population. Billing appropriately for psychotherapy services allows the care navigation team services to be partially self-supported. This model can be replicated at other centers.
Meet The Team
Care Navigation Team Model of Continuous Psychosocial Support
Long term planning, education about and completion of DPOAs and/or POLST
Dr. Catherine Madison Medical Director
Susan Sullivan, RN
Nurse Practitioner
Crisis management, education regarding behavioral strategies
To address these obstacles to delivering care, and fulfill the mission of the Brain Health Center, a Care Navigation Team (CNT) model was created to provide partially self-supporting, seamless case management and psychotherapeutic care for persons with dementia and their family and caregivers at the Brain Health Center.
Nalani Griffin Dunn MSW, LCSW
Coordinator CNT
Laura Anderson, MA
Alzheimer’s Association
Family Care Specialist
Benefits
Methods
Melissa Desuasido
Administrative Supervisor
Ymke Dioquino, MFTI
Case Management Assistant
By offering individualized, coordinated care to every patient, this unique, systematic and comprehensive model allows medical providers to focus on the continued improvement of medical care. Furthermore, the model ensures enhanced service provision, medical compliance, as well as increased safety and perceived quality of life for patients and their loved ones.
The care navigation team goal is to see every new patient by the first or second medical provider visit, and offer social work services, case management, on-site Alzheimer’s Association assistance and individual, family, and group psychotherapy.
During the first visit, CNT staff provides an explanation of services and conducts a brief assessment. Within the following two weeks care navigation team staff contacts the patient and/or family to continue the assessment process and to address any barriers to medical provider recommendations.
A care plan is then initiated that continually supports the patient in navigating the health care system from diagnosis to end of life. Our goal is to provide ongoing support throughout the patients life span to the patient and their loved ones. The care navigation team provides guidance to medical providers regarding psychological reactions to diagnoses and the impact on family dynamics. Additionally, the CNT addresses psychosocial crises, Adult Protective Services reporting and capacity issues. Psychotherapy services are billed appropriately.
Howard Hahn, MSW Intern
UC Berkeley
Problem
References
Alzheimer's Disease Facts and Figures in California: Current Status and Future Projections. February 2009. Alzheimer's Association, California Council.
Freeman HP. A model patient navigation program. Oncol Issues. September/October 2004:44-46.
Patients with cognitive impairment are typically unable to follow through on medical provider recommendations and are at risk for medical non-compliance, self-neglect and fiduciary abuse. At the same time, family and caregivers are often unprepared to deal with the many complex challenges involved in taking on the care of their loved ones.
Next Steps
Patient/family satisfaction surveys that measure quality of psychosocial support provided by the CNT and aspects of model, patients and families find especially helpful
Measurement of quantity, type of intervention, actual costs of this care and offset by psychotherapy billing
Research and continued training using cognitive behavioral therapy techniques to assist both patients and caregivers in sustained effective coping and perceived quality of life
This increases their risk of emotional stress and resulting illness to both patient and caregiver. Moreover, rising healthcare costs limit the breadth of care available in most outpatient settings.