Alzheimer’s disease, the most common neurodegenerative condition, leads to memory loss and a decline in cognitive skills. Current medication available for the disease provides only a marginal effect on the natural progression of the disease. Once diagnosed, a proper plan of care can be developed, which importantly includes education and social support for the patient, family, and caregiver in addition to medical treatment.
We remember to care. Alzheimer’s patients don’t have a cure, but they do have options. Early detection of memory loss and related dementia, using the latest equipment and expert medical personnel, is important in the establishment of a plan of care and coordination of services with the patient’s family and caregiver, who are an integral part of the care team. We believe the best way to achieve comprehensive care is a multi-disciplinary team-based approach that employs teams of medical providers who are specially trained to care for Alzheimer’s and memory disorder patients.
Core Team members To Include:
- Memory Disorder Neurologist (team leader)
- Memory Disorder Nurse Practitioner
- General Medicine Nurse Practitioner
- AD-certified Case Manager
- Social Worker
- Medical Assistant
- Team Medical Clerk
Comprehensive care requires the input of many partners, and coordination among providers in a patient-centered environment. This includes more than traditional treatment. For example, support to the caregiver is important, including education programs and depression and burnout assessment. Coordination with community partners and stakeholders is key to defragmentation of care.
Future Coordination Team members:
- Patient Navigator
- Community Partner Coordinator
- Education Coordinator
- Hospital/Transition of Care Coordinator
Comprehensive care clinics are dedicated to the highest quality of patient care while still bridging the gaps to patient and caregiver education, social services and care coordination. Ideally, patient, family and caregiver involvement and shared decision-making enhance the total care of the patient.