Addressing Dementia in Indian Country: Models of Care

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The purpose of this program is to support the development of models of comprehensive and sustainable dementia care and services in Tribal and Urban Indian communities that are responsive to the needs of persons living with dementia and their caregivers. Awardees will: 1. Plan and implement a comprehensive approach to care and services for persons living with dementia and their caregivers that addresses: Awareness and Recognition. Enhance awareness and early recognition of dementia in the community and increase referral to clinical care for evaluation leading to diagnosis. The United States Preventive Services Task Force has concluded that “current evidence is insufficient to assess the benefits and harms of screening for cognitive impairment in older adults.” Still, there is broad consensus supporting case findings to promote early recognition and diagnosis of dementia. Accurate and Timely Diagnosis. Individuals and their families should have confidence that concerns about potential cognitive impairment will be evaluated thoroughly and lead to an accurate and timely diagnosis. Most diagnoses of dementia can be made in primary care, but clinical programs should have referral and consultation mechanisms in place (either in person or via telehealth) to support diagnosis when needed. Interdisciplinary Assessment. Persons living with dementia will have complex and evolving care needs. An interdisciplinary assessment helps identify goals of care and gaps in services and sets the stage for appropriate care and services. In best practice, this assessment includes an attempt to understand the cultural, religious, and personal values that will guide goals and preferences for care. It assesses family and other caregiving resources and the needs and capabilities of those partners in care, as well as housing security and safety risks. Management and Referral. Care for the person living with dementia is guided by the assessment and most often requires coordination of health care and social services to meet their needs and support caregivers. Those living with dementia and their caregivers often need support and assistance in navigating through the various systems providing this care. Support for Caregivers. Care for persons living with dementia includes care for their caregivers.  Families and other caregivers need help in navigating services and mobilizing respite care, help in understanding what to expect and how to respond to the challenges of living with dementia, and support for self-care. Interventions that provide that care and support (e.g., REACH) and provide education and training (e.g., Savvy Caregiver) have been adapted for use in Tribal communities. 2. Develop, in collaboration with the IHS, best and promising practices to include tools, resources, reports, and presentations accessible to Federal, Tribal, and urban health programs as they plan and implement their own programs. 3. Identify and implement reimbursement and funding streams that will support service delivery and facilitate sustainability. Opportunities for reimbursement and funding streams dependent on the specific interventions planned, but potential sources might include: Medicare reimbursement through the Physician Fee Schedule, including Cognitive Assessment and Planning codes and Chronic and Complex Care Management codes. Medicaid and other state programs. Purchased and Referred Care resources. IHS and Third Party Revenue. The IHS Alzheimer’s Grant Program will provide technical assistance to grantees in development of a plan for sustainability.

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