April 16, 2019 01:48 pm Chris Crawford – Caring for patients with dementia can be challenging because there's no definitive diagnostic test and/or disease-modifying treatment.
Until better diagnostic and treatment options arise, family physicians can focus on treating what's treatable, including comorbidities, and use a navigational framework and clinical tools to more effectively assist patients and their families.
That's according to a research report published in the January/February issue of FPM that presented that framework, along with a collection of tools family physicians can use to deliver better dementia care.
These tools, many of which have been developed by the AAFP, the Alzheimer's Association and other groups, are evidence-based, user-friendly, informative and scorable and can be incorporated into electronic health records (EHRs).
"Addressing care needs of patients with dementia and their caregivers can be overwhelming for everyone," said report co-author Natalia Loskutova, M.D., Ph.D., AAFP National Research Network's (AAFP NRN's) director of evaluation. "Easy access to dementia practice tools such as assessment tools, educational resources and other information can be beneficial for providing patients and caregivers with up-to-date, trustable sources of information."
Using resources such as toolkits and bookmarked websites can be particularly helpful in improving care quality -- for example, administering necessary assessments in a time-effective manner, Loskutova told AAFP News. For example, such resources provide quick access to memory assessment tools such as the Montreal Cognitive Assessment or the Mini-Cog during a visit.
Practice tools can also provide a quick refresher on current medications and best practices when deciding on medication management strategies for the patient, Loskutova said.
"These resources are accessible as education resources for sharing with patients and their caregivers when they want to learn more about dementia and important considerations for their medical care, financial planning, end-of-life decisions or other important aspects," she said.
A research report published in the January/February issue of FPM gathered and presented evidence-based tools family physicians can use to improve care for patients with dementia.
The Dementia Management Quality Measurement Set provides clinicians with a nationally recognized, evidence-based, clearly defined and effective group of metrics that can be used to evaluate patients' current level of care and identify opportunities for quality improvement.
It's also important to keep in mind that physicians can now be paid for some dementia care services, and it's likely more will be added in the future.
The American Academy of Neurology and the American Psychiatric Association convened a workgroup of 26 members (including FPM report co-author Brian Unwin, M.D.) from 21 international organizations "to conceptualize the best possible care for patients with dementia and their caregivers and to operationalize optimal processes for delivering such care."
The resulting Dementia Management Quality Measurement Set, which was released in 2016, provides clinicians with a nationally recognized, evidence-based, clearly defined and effective group of metrics that can be used to evaluate patients' current level of care and identify opportunities for quality improvement.
The report's authors said physicians can then use established quality improvement processes, such as Plan, Do, Study, Act, to systematically target specific areas related to dementia care.
"For example, clinicians could collect baseline data on how often they diagnose dementia and then develop and initiate a plan to enhance dementia assessment and diagnosis," the report said. "They could then collect data on their plan's effectiveness and modify it as necessary."
Dementia is a complex condition that requires multiple medical and nonmedical care strategies and coordination across professionals, paraprofessionals and community services and that includes caregivers or family members in care delivery, Loskutova said.
"All of these elements are also specific to the patient's stage of disease, circumstance and care needs as the disease progresses," she added. "It's helpful to have a structured, systematic approach to developing care plans where all these factors are accounted for and revised as needed."
Physicians can use the dementia care tools highlighted in FPM to develop comprehensive and organic care plans to achieve patient-centered goals, said the report.
According to the authors, a dementia care plan has four core components:
A Dementia Care Plan Checklist included in the FPM article allows clinicians to address immediate needs, such as assessing safety to drive, while also encouraging long-range planning and goal setting, such as establishing a power of attorney and advanced directives. The checklist also may be downloaded as a PDF.
The authors recommended updating the care plan every year or when disease progression is evident.
An old adage for the care of patients with dementia is to "provide safety and structure to the patient; sanity and serenity to the caregiver," the authors noted. "Many issues of dementia care are out of anyone's control, so it is important to plan for the known, common problems that develop with this condition."
Some elements of these plans can be delegated to members of a well-trained care team with adequate resources, said the report. For example, clinical staff could administer some of the assessment tools over the telephone before a visit, asking a family member about the patient's function and cognition.
"Conducting selected tests and surveys either before or after the planned physician visit can optimize clinic workflow," the authors noted, referring to a Cognitive Impairment Visit Template available in PDF format.
The authors also suggested that practices develop protocols and provide training to enable clinical staff to help counsel patients and caregivers.
"Staff can provide patient evaluation and education handouts and connect patients and their caregivers with community resources, such as support groups and legal or financial services based on their priorities," said the report. "Embedding … links (to these resources) in the practice's EHR can improve efficiency."
It's also helpful to share care plans with other individuals who provide care, including informal caregivers, for improved communication and care coordination, Loskutova said.
Finally, physicians should remember that development of a care plan is a required element under CPT code 99483, she added.
It's important to keep in mind that physicians now can be paid for some dementia care services, Loskutova said, a situation that most likely will improve in the future.
"For example, currently, CPT code 99483 covers assessment of and care planning for patients with cognitive impairment," she said. "Chronic care management billing codes (99490, 99487, 99489) can also be used for dementia care, especially if a patient also has any other chronic condition."
For the annual assessment of cognitive function in all Medicare beneficiaries with and without cognitive impairment, the annual wellness visit (AWV) provides a reimbursable platform for a cognitive assessment, among other AWV components (G0438, G0439, G0468), Loskutova said.
"Family physicians would benefit from getting familiar with reimbursement information for these CMS codes," she noted.
The AAFP NRN's current work emphasizes additional aspects related to dementia, Loskutova said.
"First, the underdetection of dementia in primary care," she said. "It's a challenge that leaves many people who suffer from dementia and their families unaware of what causes their problems until often too late in the process."
Currently, most dementia cases are missed early on, and these individuals are not receiving the treatment, care and support they and their families need, Loskutova said.
"We are trying to bring attention to this issue by conducting research studies that show the range of benefits of timely dementia detection," she added.
Related to that, Loskutova said the AAFP NRN team is building its work to show the importance of early detection of cognitive impairment in primary care for a multitude of reasons.
"Emerging evidence shows that several major, nontherapeutic benefits of early diagnosis have been identified as important: treatable cases may be treated; comorbid conditions addressed; patients have more time to make important financial and life decisions, plan for nursing home placement and end-of-life decisions; and take prevention measures for injuries, auto accidents and elder abuse," Loskutova said.
Lastly, she said the AAFP NRN team is focused on increasing attention to brain health in general and for patients of all ages.
"We are collaborating with other organizations and brain health advocates to bring awareness to the importance of cognitive health and well-being and to enacting health care standards and polices that focus on risk reduction and comprehensive care for supporting brain health," Loskutova said. "We work to contribute to these areas through research, evidence-based practice, publications like this one and multidisciplinary collaborations."