Integrated Memory Care: Primary Care for Persons Living with Dementia

Abstract

AbstractThe Integrated Memory Care (IMC) program is a nurse practitioner led, physician‐supported primary care model which serves individuals living with Alzheimer’s disease and related dementias (ADRD) and their care partners living in the community. Individualized care plans align with patients’ goals, and patients benefit from care coordination provided by an expert team that includes nurses, social workers, occupational therapists, and dementia care assistants, all working directly with primary care providers. The IMC adds a palliative care perspective as well, emphasizing aggressive symptom management and advance care planning, thereby providing holistic care for individuals living with ADRD.Over 2000 patients and family care partners have received care at IMC since 2015. The average age of the patient population is 78.6 years; 65% of patients are female; 42% of patients are non‐white. The practice has developed and tested dementia‐specific workflows that can be implemented in a fee‐for‐service primary care environment. Successful completion of dementia quality measures, such as documentation of dementia type and stage, as well as assessment of cognitive, functional, and behavioral symptoms, is >90%. The ambulatory care sensitive admission rate of patients enrolled in the program is 0.5‐0.9%, well below published rates of 13% to 15%. In a case‐matched control group of patients, the IMC relative risk of hospitalization was one‐half those managed in usual primary care.The IMC represents a novel model of care for individuals living with ADRD and their care partners, achieving superior patient outcomes and representing a financially sustainable model for this growing population. Its primary care systems and processes provide an integrated pathway to quality care, thereby facilitating the identification of patients in the primary care setting who are living with ADRD.