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Georgia Memory Net
Georgia Memory Net is a statewide early diagnosis and care program for Alzheimer's disease and related dementias, supported by the Georgia Department of Human Services’ (DHS) Georgia Alzheimer’s Project (GAP). Georgia Memory Net established five clinics in 2018 with $4 million in state health funds. Georgia Memory Net-supported outreach and training activities provide resources to Georgia physicians and medical professionals on how to use the Medicare-supported Annual Wellness Visit (AWV) to screen for early memory loss and cognitive decline. Primary Care Physicians (PCPs) are encouraged to refer patients who demonstrate signs of memory loss and cognitive decline to a regional Georgia Memory Net Memory Assessment Clinic.
At each Memory Assessment Clinic, trained clinicians do comprehensive diagnostic assessments and care planning. Each Memory Assessment Clinic has a Community Services Educator (CSE) who works with Area Agencies on Aging (AAAs), the Alzheimer’s Association and other organizations to provide education and support for Georgians living with Alzheimer’s disease and related dementias, as well as their care partners. The Memory Assessment Clinics share diagnosis and care recommendations with the patient’s Primary Care Physician, 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 even more Georgians will have access to these vital diagnostic services.
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 Memory Assessment Clinics around the state that can accurately diagnose Alzheimer's and related dementias, and improve care.
3) Support the Georgia Alzheimer’s Project’s oversight and evaluation of project performance and direct data collection to the Alzheimer's Registry in the Georgia Department of Public Health.
Working with many partners, Emory University serves as the primary implementing partner for the project, providing the clinical workflow model for Georgia Memory Net. The Georgia Department of Human Services (DHS) and its Division of Aging Services (DAS) oversee all aspects of Georgia Memory Net development, implementation and reporting. These agencies also keep the Georgia General Assembly 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 Georgia Memory Net on educational efforts, advocacy, workforce development and other areas.
For Georgia Memory Net’s first few years, academic medical center partners will focus on Georgia Memory Net clinic implementation. The Medical College of Georgia at Augusta University; Medical College of Georgia affiliates based in Albany, GA within the Phoebe Putney Health System; Mercer University School of Medicine in Macon (Navicent Health); Mercer affiliates based at Columbus Regional Medical Center; and the Morehouse School of Medicine at Grady Memorial Hospital in Atlanta have established the first five Georgia Memory Net sites.
In addition to Georgia Memory Net’s partnerships with academic medical centers, many community and education service partners are key to the project’s success and to the improvement of the health and quality of life for Georgians with dementia and their families. The Area Agencies on Aging (AAA), the state Aging and Disabilities Resource Connection (ADRC), the Alzheimer’s Association and the Rosalynn Carter Institute for Caregiving all serve vital roles in Georgia Memory Net. These agencies work closely with Georgia Memory Net leadership to develop infrastructure and workflow for implementing the comprehensive care plan.
The Emory Alzheimer's Disease Research Center leadership and technical assistance groups will provide training, funding and ongoing evaluation for each Georgia Memory Net Memory Assessment Clinic.
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 prevent 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 clinics with linkages to social and community services is 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.
All Georgia Memory Net Memory Assessment Clinics are required to register patients who meet the criteria for Alzheimer’s or related dementias in the Alzheimer’s Disease and Related Dementias State Registry. This data helps Georgia plan for current and future healthcare and social service needs.
Georgia Memory Net collects 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. To enhance the ability of clinical and public health experts to better estimate the number of Georgians living with dementia, diagnosis information, including estimated stage of illness at time of diagnosis, is captured. This information is shared with the Alzheimer’s Disease and Related Dementias State Registry.
Georgia Memory Net also surveys family or other care partners approximately every six months, using validated tools to measure levels of care partners’ stress and burden. These data help us ensure the highest quality of service delivery and care, and informs our programs’ ability to reduce caregiver burden via our linkage to care system. We monitor caregiver information over time to measure the longer-term effects of Georgia Memory Net on family members and other care partners.
The number of referrals to each Georgia Memory Net Memory Assessment Clinic is also monitored as a way to track Georgia’s regional needs. Memory Assessment Clinics report performance indicators including wait times and patient wait lists so Georgia Memory Net can determine where an increased number of providers or resources may be needed.
Over the long term, Georgia Memory Net will track data provided by the Center for Medicare and Medicaid Services (CMS) relating to Emergency Room visits, repeated hospital admissions and skilled nursing placements. These data will help us determine the estimated diversion of unnecessary care transitions and the resulting cost savings to the state. Georgia Memory Net will also monitor Primary Care Physicians’ 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.
Georgia Memory Net operates in complete compliance with the US Health Insurance Portability and Accountability Act (HIPAA) privacy and confidentiality rules. No patient data is shared outside the network of protected entities without patient permission.
Legal, Information Technology (IT) and Georgia Memory Net administration teams are developing a comprehensive authorization to facilitate a streamlined process by which patients can approve data sharing with appropriate clinical providers, the Area Agencies on Aging, the Aging and Disabilities Resource Connection and the Alzheimer's Association, signing as few forms as possible.
Georgia Memory Net Memory Assessment Clinics share information collected from the patient visit pertaining to diagnosis (type of dementia), estimated stage of illness and general demographic information with the Georgia Alzheimer’s Disease and Related Dementias (ADRD) State Registry, which is governed by the Department of Public Health (DPH) and therefore outside of the Georgia Memory Net purview. Sharing of data to the ADRD Registry does not require an authorization, as the ADRD is governed by DPH and by Georgia law is exempt (public health data collection exempt from explicit authorization).
Medical and psychosocial information relevant to clinical and community care planning is back to the Primary Care Physician from which the patient or care partner received the Georgia Memory Net referral. Information pertaining to community services care planning is shared with the Georgia Alzheimer’s Association and affiliated local chapters as well as with the patient’s local Area Agencies on Aging or Aging and Disabilities Resource Connection office. Information provided to state agencies for performance reporting, publications for peer-reviewed journals or other presentation formats is shared in aggregate form only and doesn’t include individuals’ Protected Health Information (PHI).
PCPs and Referrals
Access to Georgia Memory Net clinic services requires a referral from a Primary Care Provider (PCP). Potential patients should discuss their memory concerns with their PCP, who can provide a Georgia Memory Net Memory Assessment Clinic referral if they meet the referral criteria.
Each year, Medicare-eligible adults should receive their Annual Wellness Visit (AWV), a Centers for Medicare and Medicaid Services (CMS) reimbursable health screening. Primary Care Physicians (PCP) 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 three minutes to complete. If a patient's Mini-Cog results indicate an impairment in memory or cognitive function, the PCP can refer the patient to their local Georgia Memory Net for further 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 Memory Assessment Clinic.
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 Georgia Memory Net to streamline the process of delivering diagnostic and care planning expertise.
General neurologists treat a wide range of conditions and diseases affecting the nervous system. 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, Georgia Memory Net provides its Memory Assessment Clinics with access to cognitive neurologists, Emory clinicians and scientists specializing in memory issues and cognitive decline, and 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 Primary Care Physician, 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.
Georgia Memory Net will train Primary Care Providers 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 providing the best care for dementia patients and their families in primary care settings to ensure they’re equipped to care for their patients in the long term following their Memory Assessment Clinic visits.
As Memory Assessment Clinics go from pilot to full operations, Georgia Memory Net will deliver regional messaging in digital and live format via webinars regarding referral processes via AWVs, expectations of PCP-to-Memory Assessment Clinic communications and care continuity instruction. Georgia Memory Net will offer regional and statewide conferences in partnership with various professional organizations like the Georgia Academy of Family Physicians, or the Gerontological Advanced Practice Nurses Association.
The Community Service Educator meets with Georgia Memory Network patients and their care partners to provide initial support and education, assess initial care needs, develop written care recommendations and link the patients and care partners with community resources that can provide ongoing support, like the Alzheimer’s Association and the local Area Agency on Aging.
No. Georgia Memory Net Memory Assessment Clinics are not designed to provide ongoing patient care, so the Community Services Educator is not able to provide ongoing care coordination, case management or counseling services. The CSE connects 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.
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.