Georgia Memory Net Supports Patients Through Their PCP. Here’s How It Works.

The rate of increase for Alzheimer’s in the state of Georgia is high compared to much of the U.S. It’s a problem that’s only getting worse and it’s one of the reasons that Georgia Memory Net was born. Supported by the Georgia Department of Human Services’ Georgia Alzheimer’s Project, along with partners in Georgia academic institutions, community organizations, professional associations, as well as the State Aging and Disabilities Resource Connection Network, Georgia Memory Net works to improve screening and care of Georgians with memory loss and other cognitive impairments linked to Alzheimer’s and related dementias.

The development of Georgia Memory Net is big news and here’s how it can make a real difference for patients and families dealing with Alzheimer’s and other related dementias:

Georgia Memory Net provisions PCPs with the tools to care for Alzheimer’s patients

There has been a sense of futility in the primary care community regarding to Alzheimer’s. In the past, there have been few linkages to support services., resulting in many unnecessary hospital admissions and readmissions that should be avoidable. This puts a burden on the entire healthcare system and it comes from a lack of information on what can and should be done in these cases.

This is why Georgia Memory Net was born. We’re addressing this challenge through three main priorities:

1. Increase education and support for primary care providers throughout the State of Georgia to promote earlier recognition of cognitive difficulties or symptoms

2. Link practitioners to regional centers of expertise, known as Memory Assessment Clinics (MACs) to provide a very specific diagnoses and develop a treatment plan to be implemented by the PCP

3. Connect patients, families and other care partners to services and educational resources from partners such as Area Agencies on Aging (AAAs), The Alzheimer’s Association and The Rosalynn Carter Institute for Caregiving to ensure everyone has the planning and support they need to face the journey ahead

One of our primary efforts to increase screening and identification of cognitive conditions is to promote the use of the Annual Wellness (AWV) visit and its cognitive screening evaluation. Identifying Alzheimer’s and related dementias through this method will help destigmatize the conversation between patients and PCPs, as cognitive screening can become just one of many health screens performed during this annual exam. If an AWV identifies a potential issue, patients can then be referred to one of the regional MACs for a stage 2 evaluation.

Regional MACs can better reach minority and underserved populations

The risk of Alzheimer’s and related dementias is 60-80% higher among African Americans and Hispanics compared Caucasian populations. And yet awareness and research into these high-risk groups is severely lacking.

As an example, consider AGNI, the Alzheimer's Disease Neuroimaging Initiative. This research is the foundation of the spinal fluid profiles often used to confirm conditions such as mild cognitive impairment or Alzheimer’s. But this research relies on a patient population that is 97% Caucasian . The question we must ask is: “Are we really certain that the markers we are using to confirm a case of Alzheimer’s or other form of dementia accurate when caring for minority populations?”

While not able to address research issues directly, Georgia Memory Net is able to target services to better meet the needs of minority and other underserved groups. MACs are geographically distributed to be accessible to minority populations in urban centers, while balanced with other rural locations where access to expert care can be highly limited.

Georgia Memory Net increases access to care

To assist populations that have previous struggled to receive treatment for cognitive conditions, Georgia Memory Net MACs provide Community Service Educators (CSEs) as a non-billable to service to patients and families to help connect each patient with a tailored care profile. We also work with Federally Qualified Health Centers (FQHCs) to help those struggling with health coverage to both receive screening services and to be able to deliver care once a treatment plan is devised.

Here’s how it works:

• During the first visit, a patient and their care partner(s) will meet with a CSE and undergo detailed cognitive testing up and above what’s available in the AWV. Any necessary labs and imaging are performed in order to make a specific diagnosis.

• During the second visit, a clinician and the CSE will establish a care plan and then a “warm hand off” will occur for the patient to return to their PCP. The patient and care partner will also be connected with local resources and support to protect the physical and emotional health of both parties.

• Another essential componential of the Georgia Memory Net model is tracking and reevaluation. We follow patients to ensure their treatment is working effectively and to provide continuing education and support. We also constantly search for new ways to provide better care for patients and to ensure stronger relationships within the PCP community.

How this benefit PCPs

Once a possible cognitive condition is identified, a stage 2 evaluation is typically a two-hour visit not often covered by private insurance or Medicare. Georgia Memory Net alleviates this burden from physicians and prepares them for the next stage of care with a specific diagnoses and treatment plan. Beyond clinical treatments such as medication, Georgia Memory addresses continuing education and support needs for patients and families, as they are often their own best advocates, and sit squarely at the center of the spectrum of care. Whether it’s patient and families, or the clinicians that care for them, our goal at Georgia Memory Net is to make sure that no one is ever alone when charting the path forward to deal with Alzheimer’s or any other cognitive issue. It’s how we plan to make a substantive improvement in the health of the aging population in the State of Georgia, and a model we hope to someday rollout nationwide.