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What is the Georgia Memory Net?

The Georgia Memory Net is a statewide early diagnosis and treatment program for Alzheimer's disease and related disorders and dementias, supported by the Georgia Department of Human Services’ (DHS) Georgia Alzheimer’s Project (GAP). The Georgia Memory Net will establish five centers in FY18, with $4 million in state health funds. Georgia Memory Net supported outreach and training activities will provide resources to Georgia physicians and medical professionals about using the Medicare-supported Annual Wellness Visit (AWV) to screen for early memory loss and cognitive decline. Primary care providers (PCPs) will be encouraged to refer patients who demonstrate signs of memory loss and cognitive decline to a regional Georgia Memory Net center.

At the centers, trained clinicians will initiate comprehensive diagnostic assessments and care planning. Each center will have a Community Services Educator (CSE) who will work with Area Agencies on Aging (AAAs), the Alzheimer’s Association, and other organizations to provide education and support for individuals living with Alzheimer’s disease and related disorders, as well as their care partners. The centers will communicate diagnosis and treatment recommendations to the patient’s PCP, so the provider is better prepared to treat the patient’s memory issues and cognitive decline. Georgia Memory Net expansion is anticipated in the future, so more Georgians will have access to these vital diagnostic services.

What are the main goals of the Georgia Memory Net?

There are three main goals of Georgia Memory Net:

1) Improve the screening of Georgians with memory loss with a sustainable Annual Wellness Visit (AWV) model.

2) Establish centers around the state that can accurately diagnose Alzheimer's and related disorders and dementias and improve care.

3) Support the Georgia Alzheimer’s Project’s oversight and evaluation structure of project performance and direct data collection to the Alzheimer's Registry in the Georgia Department of Public Health.

Who is involved?

Working alongside myriad partners, Emory University serves as the primary implementing partner for the project in providing the clinical workflow model for the Georgia Memory Net. The DHS and its Division of Aging Services (DAS) oversee all aspects of Georgia Memory Net development, implementation and outcomes reporting. These agencies will also keep Georgia General Assembly members apprised of the progress and fiscal responsibility of Georgia Memory Net administration. Georgia Alzheimer’s and Related Dementias (GARD) State Plan Collaborative, a task force consisting of private, nonprofit and government agency representatives, will partner closely with the Georgia Memory Net on educational efforts, advocacy, workforce development and other pertinent areas.

For Georgia Memory Net’s first year, academic medical center partners will embark on Georgia Memory Net center implementation. The Medical College of Georgia at Augusta University, as well as Medical College of Georgia affiliates based in Albany, GA within the Phoebe Putney Health System, Mercer University School of Medicine in Macon (Navicent Health) and Mercer affiliated based at Columbus Regional Medical center, along with the Morehouse School of Medicine at Grady Memorial Hospital in Atlanta will establish the first five Georgia Memory Net sites.

In addition to Georgia Memory Net’s partnerships with academic medical centers, numerous community and education service partners are key to the project’s success and to the improvement of the health and quality of life for persons with dementia and their families. The Area Agencies on Aging (AAA) and state Aging and Disabilities Resource Connection (ADRC), Alzheimer’s Association, and Rosalynn Carter Institute for Caregiving, serve vital roles in the Georgia Memory Net. These agencies work closely with Georgia Memory Net leadership to develop infrastructure and work flow for providing effective linkages to care and implementation of the comprehensive care plan.

The Emory Alzheimer's Disease Research Center leadership and technical assistance cores will provide training, funding, and ongoing evaluation for each Georgia Memory Net center.

Why is Georgia Memory Net needed?

There are approximately 140,000 Georgians who have Alzheimer's Disease, and that number is expected to increase to 190,000 by 2025. In 2016, the Behavioral Risk Factor Surveillance System (BRFSS) survey found that more than 385,000 Georgians have self-reported Perceived Cognitive Impairment (PCI) but 80 percent of them had not discussed the symptoms of memory loss with a provider and thus had received no evaluation or treatment for the condition. Implementing a program for early diagnosis and treatment in Georgia will support care of individuals in their homes and prevents unnecessary visits to emergency departments and hospital admissions. This translates to a savings of $1.3 billion and possibly as much as $1.6 billion.

Access to diagnostic centers with linkages to social and community services are essential for early diagnosis and effective management of individuals living with Alzheimer’s and related disorders. These services will reduce delays in diagnosis and facilitate early interventions to alleviate symptoms and support the well-being of patients and care partners.

How do Georgia Memory Net centers use the Alzheimer’s Disease and Related Dementias State Registry (ADRD)?

All Georgia Memory Net centers will be required to register patients who meet the criteria for Alzheimer’s or related dementias in the ADRD. This data will enable the state to plan for current and future health care and social service needs

What data is being collected for the purposes of this project?

The Georgia Memory Net will collect data pertaining to prevalence of Alzheimer’s Disease and related dementias, patient quality of health and life, care partner burden, and systemic or institutional burden. In order to enhance the ability of clinical and public health experts to more accurately estimate the number of Georgians living with dementia, diagnosis information (i.e. specific disease type) including estimated stage of illness at time of diagnosis will be captured. This information will be shared with the ADRD Registry, as noted above.

The Georgia Memory Net will also survey family or other care partners approximately every 6 months, using validated tools to measure level of care partners’ stress and burden. These data will aid us in ensuring highest quality of service delivery and care, and will inform our programs’ ability to reduce caregiver burden via our linkage to care system. We will monitor caregiver information over time to measure the longer term effects of the Georgia Memory Net on family members and other care partners.

The number of referrals to each Georgia Memory Net center as well as amalgamated at the state level to determine regional and statewide level of need will also be tracked. Centers will report performance indicators including wait times and patient wait lists so the Georgia Memory Net can determine where an increased number of providers or resources may be needed.

Furthermore, over the long term, the Georgia Memory Net will track data provided by the Center for Medicare and Medicaid Services (CMS) relating to ER visits, repeated hospital admissions, and skilled nursing placements. This data will help us determine the estimated diversion of unnecessary care transitions and the resulting cost savings to the state. The Georgia Memory Net will also monitor PCP rates of Annual Wellness Visits (AWVs) statewide to ensure that eligible older adults are receiving this routine, reimbursable care in order to increase rates of cognitive screening in a routine, less stigmatizing, fashion.

How are patient data being protected? Will information be shared outside the GA Memory Net?

The Georgia Memory Net operates in complete compliance with HIPAA privacy and confidentiality rules; no patient data will be shared outside the network of protected entities without patient permission.

Legal, Information Technology (IT), and Georgia Memory Net administration teams are working to develop a comprehensive authorization to facilitate a streamlined process by which patients can approve data sharing with appropriate clinical providers, the AAA/ADRC, and Alzheimer's Association, signing as few forms as possible.

Georgia Memory Net centers will share information collected from the patient visit pertaining to diagnosis (type of dementia), estimated stage of illness, and general demographic information with the Georgia ADRD Registry, which is governed by the DPH and therefore outside of the Georgia Memory Net purview. Sharing of data to ADRD Registry does not require authorization, as the ADRD is governed by DPH and by Georgia law is exempt (public health data collection exempt from explicit authorization).

Medical and psycho-social information relevant to clinical and community care planning will be shared back to the PCP, from which the patient or care partner received the Georgia Memory Net referral. Information pertaining to community services care planning will be shared with the Georgia Alzheimer’s Association and affiliated local chapters as well as with the patient’s local AAA/ADRC office. Information provided to State agencies for performance reporting, publications for peer reviewed journals or other presentation formats, will be shared in aggregate form only and will not include individuals’ Protected Health Information (PHI).

What are Georgia Memory Net center implementation timelines?

The Georgia Memory Net began in July 2017, and five geographically diverse center sites will become operational on a rolling basis by June 30th, 2018. Throughout the process, Georgia Memory Net leadership and DHS will provide region-specific information, including detailed timelines of service implementation, and provide Georgia Memory Net partners and constituents with pertinent information to share with their respective constituents, clients, patients and other relevant partners. The initial pilot site in Augusta, Georgia began the training and pilot implementation phases in mid-fall, 2017. The remaining four Georgia Memory Net partners will continue to implement pilot roll outs and full center operations in mid to late spring, 2018.

How can I help someone access Georgia Memory Net center services?

Access to Georgia Memory Net center services will require a referral from a PCP. Potential patients should discuss their memory concerns with their primary care provider, who can provide a Georgia Memory Net center referral if they meet the referral criteria.

How does the referral process work?

Each year, Medicare eligible adults should receive their Annual Wellness Visit (AWV), a Centers for Medicare and Medicaid Services (CMS) reimbursable health screening. PCPs perform the AWV to determine risk factors for chronic illnesses, including dementia. The Mini-Cog is a non-invasive cognitive screening tool embedded in the AWV that takes about 3 minutes to complete. If a patients’ Mini-Cog results indicate an impairment in memory or cognitive function, the PCP can refer the patient to his/her local Georgia Memory Net for further neuropsychological testing and a diagnostic visit with the trained provider. Alternatively, if the PCP conducts the Mini-Cog outside of the AWV or otherwise indicates notable impairment in memory, that provider may also refer the patient to the local Georgia Memory Net center.

Why can only Primary Care Providers (PCPs) make referrals?

Many medical and mental health issues may mask as Alzheimer’s or other types of dementia. Physicians or Advanced Practice Providers, such as Nurse Practitioners or Physician Assistants, are best equipped to rule out some of the masking disorders, including thyroid or Vitamin B disorders, depression, and side effects of particular medications or combinations of medications. Using the PCPs to determine the greatest likelihood of a dementia prior to making the referral enables the Georgia Memory Net to streamline the process of delivering diagnostic and care planning expertise.

Why would a Primary Care Provider (PCP) refer a patient to a Georgia Memory Net center instead of another local neurologist? What makes these centers different?

General neurologists treat a wide range of conditions and diseases affecting the nervous system, whereas cognitive neurologists specialize in treating patients with memory loss, dementia, and cognitive dysfunction. There are few cognitive neurologists in Georgia outside of Atlanta. Using telehealth and consultative resources, the Georgia Memory Net provides participating centers with access to cognitive neurologists, and Emory clinicians and scientists specializing in memory issues and cognitive decline, as well as a community service educator (CSE) for care recommendations. Moreover, Georgia Memory Net staff has the education and resources to follow-up with a patient’s local PCP, ensuring that they are well-equipped to continue caring for their patients with memory issues and cognitive decline, since many patients are unable to regularly visit a neurologist due to geographic distance or scheduling constraints.

How are Primary Care Providers (PCPs) being trained to identify Georgia Memory Net appropriate patients and explain the program?

The Georgia Memory Net will train PCPs on how to conduct and bill for the Annual Wellness Visit (AWV), ensuring the Mini-Cog is conducted within the AWV. PCPs will also receive training on provision of best care for dementia patients and their families in primary care settings to ensure they are equipped to care for their patients in the long-term, following their center visits.

As centers go from pilot to full operations, the Georgia Memory Net will deliver regional messaging in digital and live format via webinars regarding referral processes via AWVs, expectations of PCP-Georgia Memory Net center communications, and care continuity instruction. The Georgia Memory Net will offer regional or statewide conferences in partnership with various professional organizations (e.g. Georgia Academy of Family Physicians, Gerontological Advance Practice Nurses Association).

What is the role of the Community Services Educator (CSE)?

The CSE will meet with Georgia Memory Network patients and their care partners to provide initial support and education, to assess initial care needs, to develop written care recommendations, and to link the patients and care partners with community resources who can provide ongoing support, like the Alzheimer’s Association and the local Area Agency on Aging.

Will the Community Services Education (CSE) maintain a care coordination or counseling role following the patients’ Georgia Memory Net center visit?

No. The Georgia Memory Net centers are not designed to provide ongoing patient care, so the CSE will not be able to provide ongoing care coordination, case management or counseling services. The CSE will connect people living with dementia and their care partners to local community resources that can address their individualized needs. These resources may include the Area Agencies on Aging, the Alzheimer’s Association, and the Rosalynn Carter Institute for Caregiving.

Who should I contact if I want more information?

Please contact Program Director Rebecca Dillard at and Program Coordinator Michaela Walker at for more information.

Georgia Memory Net At-A-Glance

Georgia Memory Net At-A-Glance

Why is Georgia Memory Net here? There’s so much information about Alzheimer’s and related dementias in Georgia, and how to diagnose and treat them, that it can become overwhelming. We’ve done our best to simplify the info into a clear one-page infographic.

Why is Georgia Memory Net here? There’s so much information about Alzheimer’s and related dementias in Georgia, and how to diagnose and treat them, that it can become overwhelming. We’ve done our best to simplify the info into a clear one-page infographic.

Geogia Memory Net Infographic