MGS WEBINAR - mngero.org … · NOTE: A cut point of
Transcript of MGS WEBINAR - mngero.org … · NOTE: A cut point of
MGSWEBINAR:
BestPrac*cesforCogni*veScreening&Demen*aCarePlanning
Basedon:
BestPrac*cesforOp*mizingDemen*aCareforCareCoordinators
Objec*ves
• Understandthera*onaleforusingcogni*veassessmentinstrumentswitholderclients
• Learnhowtoadminister,score,andinterprettheMini-Cog
• Learnhowtocommunicateassessmentresultstoclientsandpreparethemforadoctor’svisitandmemorywork-up
• Employbestprac*cesincareplanningandcarecoordina*onforpa*entswithdemen*aandtheircarepartners
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Introduc*onto
ACTonAlzheimer’s
WhatisACTonAlzheimer’s?
statewide
collaborative
volunteer driven
60+ O R G A N I Z A T I O N S 500+
I N D I V I D U A L S
I M P A C T S O F A L Z H E I M E R ’ S
BUDGETARY SOCIAL PERSONAL
FocusonQualityHealthCare
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www.ACTonALZ.org
ACTToolKit
• Evidence-andconsensus-basedbestprac*cestandardsforAlzheimer’scare
• Toolsandresourcesfor:– Primarycareproviders– Carecoordinators– Communityagencies– Pa*entsandcarepartners
7 www.actonalz.org/provider-pracLce-tools
HealthCareSeXngs:CareCoordina*on
www.actonalz.org/provider-pracLce-tools
Demen*aandAlzheimer’s
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Demen*aDiagnoses
Alzheimer’sDisease
VascularDemen*a
LewyBodyDemen*a
FTD Alzheimer’sdisease:60-80%• IncludesmixedAD+VD
LewyBodyDemen*a:10-25%– Parkinsonspectrum
VascularDemen*a:6-10%– Strokerelated
FrontotemporalDemen*a:2-5%– Personalityorlanguage
disturbance
DiseaseEduca*on:WhatisAD?
11 hbp://youtu.be/ECbjK4Ra-Ys
StagesofAlzheimer’sDisease
Alzheimer’sDisease:ChallengesandOpportuni*es
Alzheimer’s:APublicHealthCrisis
• Scopeoftheproblem– 5.4MAmericanswithADin2016– Growingepidemicexpectedtoimpact13.8MAmericansby2050andconsume1.1trillioninhealthcarespending
– Almost2/3arewomen(longerlifeexpectancy)– Ifdiseasecouldbedetectedearlierincidencewouldbemuchhigher
• Pre-clinicalstage1-2decades
• Somepopula*onsathigherrisk– OlderAfricanAmericans(2xaswhites)– OlderHispanics(1.5xaswhites)
14 Alzheimer’s Association Facts and Figures 2016
BaseRates
• 1in9people65+(11%)• 1in3people85+(32%)
15 Alzheimer’s Association Facts and Figures 2016
Ages of People with Alzheimer’s Disease in the United States
• Apopula*onwithcomplexcareneeds
• Indisputablecorrela*onbetweenchroniccondi*onsandcosts
Pa*entswithDemen*a
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2.5chroniccondiLons(average)
5+medicaLons(average)
3Lmesmorelikelytobehospitalized
ManyadmissionsfrompreventablecondiLons,withhigherperpersoncosts
Alzheimer’s Association Facts and Figures 2014
Challenges&Opportuni*es
• ADunder-recognizedbyproviders– Fewerthan50%ofpa*entsreceiveformaldiagnosis
• Millionsunawaretheyhavedemen*a– Diagnosisokendelayedonaverageby2-5yearsakersymptomonset
– Significantimpairmentinfunc*onby*meitisrecognized
• Poor*ming:diagnosisfrequentlyat*meofcrises,hospitaliza*on,failuretothrive,urgentneedforins*tu*onaliza*on
17 Boise et al., 2004; Boustani et al., 2003; Boustani et al., 2005; Silverstein & Maslow, 2006
1. Improvedmanagementofco-morbidcondi*ons
2. Reduceineffec*ve,expensive,crisis-drivenuseofhealthcareresource
3. Improvequalityoflife• Pa*entscanpar*cipateindecisions• Decreaseburdenonfamilyandcaregivers
4. Intervenetopromoteasafeandhappyenvironmentthatsupportsindependence
Ra*onaleforTimelyDetec*on
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Iden*fyingCogni*veImpairment
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HowYouCanHelp
• Firststepsareawarenessandrecogni*on– Beawareoftheprevalenceofdemen*a&importanceofgeXngadiagnosis
– Facilitatemedicalwork-up
• Assesscogni*on• Provideresourcesandinforma*ontopa*entsandfamilymembers
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Prac*ceTips
• Okensignsandsymptomsarenotrecognizedun*ltheyarequitepronounced– Abribu*onerror:“Whatdoyouexpect?Sheis80yearsold.”
– RedFlag:Subjec*veimpressionsFAILtodetectdemen*ainearlystages
– Useofanobjec*vetooltoevaluatecogni*onisfarsuperiortopersonalopinion
Mini-CogImproves Physician Recognition
***
*** ***
CDR Stage MCI Mild Mod Sev
% C
orre
ct
Borson S et al. Int J Geriatr Psychiatry 2006; 21: 349
0
20
40
60
80
100
0.5 1 2 3
Mini-Cog Patient’s own physician
*** p < .001
Iden*fyingCogni*veImpairment
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Cogni*veImpairmentID
Cogni*veAssessmentTools
• Widerangeofop*ons– Mini-Cog™(MC)– Mini-MentalStateExam©(MMSE)– St.LouisUniversityMentalStatusExam™(SLUMS)– MontrealCogni*veAssessment™(MoCA)– RowlandUniversalDemen*aAssessment(RUDAS)
• AllbutMMSEfree,inpublicdomain,andonline
www.actonalz.org/screening-diverse-popula*ons
Borson et al., 2000; Folstein et al., 1975; Nasreddine 2005; Tariq et al., 2006
Administra*onBestPrac*ces
• Trynotto:– Usethewords“test”or“memory”
• Instead:“We’regoingtodosomethingnextthatrequiressomeconcentra.on”
– Allowpa*enttogiveupprematurelyorskipques*ons
– Deviatefromstandardizedinstruc*ons– Offermul*plechoiceanswers– Besokonscoring
– Scorerangesalreadypaddedfornormalerrors– Deductpointswherenecessary–bestrict
Mini-Cog™
Contents• VerbalRecall(3points)• ClockDraw(2points)
Advantages• Quick(2-3min)• Easy• Highyield(execu*vefx,
memory,visuospa*al)
Subjectaskedtorecall3wordsLeader,Season,Table
Subjectaskedtodrawclock,sethandsto10past11
+3
+2
Borson et al., 2000
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www.actonalz.org/sites/default/files/documents/Mini-Cog_.pdf
Mini-Cog
Pass• >4
Fail• 3orless
Borson et al., 2000; Borson, Scanlan, Chen et al., 2003; Borson, Scanlan, Watanabe et al., 2006; Lessig, Scanlan et al., 2008; McCarten, Anderson et al., 2011; McCarten, Anderson et al., 2012; Tsoi, Chan et al., 2015
NOTE:Acutpointof<3ontheMini-Coghasbeenvalidatedfordemen.ascreening,butmanyindividualswithclinicallymeaningfulcogni.veimpairmentwillscorehigher.Whengreatersensi.vityisdesired,acutpointof<4isrecommendedasitmayindicateaneedforfurtherevalua.onofcogni.vestatus.
Mini-CogResearch
• Performanceunaffectedbyeduca*onorlanguage• BorsonIntJGeriatrPsychiatry2000
• Sensi*vityandspecificitysimilartoMMSE(76%vs.79%;89%vs.88%)
• BorsonJAGS2003
• Failureassociatedwithinabilitytofillpillbox• AndersonetalAmSocConsultPharmacists2008
Mini-Cog:Colleen
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http://youtu.be/DeCFtuD41WY
Colleen’sClock
Colleen’sScore
Communica*ngResultsofCogni*ve
AssessmenttoPa*entsandHealthcareProviders
Workflow:TheBigPicture
1. Administercogni*veassessmenttool2. Discussresultswithclient/pa*ent3. Recommendnextsteps,follow-up4. Considerprovidingwribendocumenta*on
to:– Client/pa*entandfamily– Physician/medicalprovider
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Prepara*on
• Beforeusinganassessmenttool:– Makesureyouprac*ceandarecomfortablewithalladministra*onandscoringguidelinesofthetool(s)
– Usepartsorallofthescriptsprovidedinthiswebinarasabasisforprovidingfeedbacktoclients/pa*entsandotherhealthcareprovidersregardingassessmentresults
• Yourscriptmayvary,inpart,onyouruniqueprofessionalroleandwhetheryouareworkinginsideamedicalclinicorinacommunityhealthcareagency/seXng
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Prepara*on
• Writedownyourscriptsandprac*cedeliveringthemun*lyoucan:– Providetheinforma*onclearlyandsuccinctly– Offerfeedbackcalmly,inamaber-of-facttone,
withoutanxiety• Anytension/anxietyyouhavewillbeprojected
ontoclients/pa*ents• Keepyourscriptsonhandatall*mes(withyour
screeningtools)soyoualwayshavethemforreference,whenneeded
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Prepara*on
• Neverusethewords“demen*a”or“Alzheimer’sdisease”– Screeningtoolsarenotdiagnos*c– Usingthesetermsisprematureatthisstageandcancontributetoanxiety/fear
• Avoid– Beingunnecessarilywordy– Over-explainingorra*onalizingtheprocess
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ClientReac*ons
• Youshouldplanforawiderangeofclientreac*onstoassessmentresults
• Responsesmayrangefromacceptancetorejec*on– SomealreadyworriedabouttheirmemoryandareinterestedingeXnganswers
– Othersmaybesurprisedbyresults,butwillingtofollow-up
– Somemaynotbeawareofproblem(forgeXngtheyareforgezul)orreadytoaccepttheinforma*on
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ClientReac*ons
• Lackofacceptancecanbeaneffec*vemechanismto:– Preservesenseofself(ideaofcogni*veimpairmentmayposethreattoiden*ty,self-worth)
– Managefearandanxietyaboutthefuture
• Readinesstoact– Maybeagradualprocessrequiringmul*pleinterac*onswiththeclient/pa*ent
• Posi*veoutcomesarepossibleinacontextinwhichsomenega*vereac*ons/feelingsoccur
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SampleScript:ThePurpose
• Regardlessofapassingorfailingscore,explainthepa*ent’stestresultbyfirstremindingthemoftheassessmentpurpose:
• “Thepurposeofthistaskwastocheckonthehealthofthebrainanddetermineifthereisanyneedforfurtherevalua*onofyourmemory.”
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SampleScript:PassingScore
• “Youobtainedanormalscoreonthismeasure,whichisgoodnews.Noaddi*onalac*onisneeded.”
• “However,ifyouhaveconcernsaboutyourthinkingormemory,talkto[contact]yourdoctor.”
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SampleScript:FailingScore
• Outsideclinic– “Yourscoreonthemeasurewasaliblebitlowtoday.Thismeansitwouldbegoodtocontactyourdoctorsothathe/shecanbeproac*veandtakeacloserlookathowyouaredoing.”
– “Therearemanyreasonswhysomeonemightreceivealowscore.Apersonmightbe*red,havealotontheirmind,feelstressedorbedistracted.Inothercases,theymightbetakingmedica*ons,haveashortageofcertainvitaminsornutrients,orhaveamedicalcondi*onthatiscausingmemoryloss.”
– “Contac*ngyourdoctorisimportantsopoten*alproblemscanbeiden*fiedasearlyaspossible.Thisisavitalpartofstayinghealthy.”
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OpeningUpConversa*on
• Usetheassessmentprocessasaopportunitytodiscussmemoryissuesopenlyandtoworkfromtheperspec*veofyourpa*ent/client:– “Areyouhavinganytroublewithyourmemoryorthinking?”
– Ifyes,“Whatdoyouthinkmightbecausingthis?”– “Haveyoutalkedwithanyoneaboutit?”– “Haveyoutalkedwithyourdoctoraboutthis?”Ifso,“Whathappened?”
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CareCoordina*on
• Helpfacilitateanappointmentwiththedoctorasmuchastheclient/familywillallowand/orasmuchasyouareabletowithinyourrole.– Themoreyoucando,themorelikelyfollow-upwilloccur
• Sitwithfamilywhileacallismadetosetupdoctorappointmentand/or
• Callclient/familyin1weektocheckonprogress• Accompanyclienttothedoctor
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CareCoordina*on
• Promoteposi*ve,health-focusedmessages• Encourageinvolvementoffamilymembers
– Familymember(s)shouldaccompanypa*ent/clientandpar*cipateindoctorvisit
– Writedowntheirobserva*onsre:cogni*ve,behavioral,andfunc*onalchangesinbulletpointstyleandgivetodoctorduringappointment
• Closetheloop– “Iwouldliketosee/talkwithyouagainakeryoufollow-upwithyourdoctoraboutthis.Doesthatsoundreasonabletoyou?”
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CareCoordina*on
• Considerprovidingwribendocumenta*ontotheclient/familyand/ortheirdoctor,ifappropriate– Samplelebersareavailablefordownloadatwww.actonalz.org/video-tutorials
– Followyourorganiza*on’sexis*ngHIPAAguidelines
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CareCoordina*on
• Clinicshavetocopewithalotofpaperworkandsome*meslebersgetlost– Encouragepa*ent/familytobringacopyofthelebertotheirdoctorappointment
– Youmayfindthat,insomecircumstances,youhavetofaxormailtheproviderlebertotheclinicmorethanonce
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Q&A
• WhatwillthedoctordowhenIseehim/her?– He/shewillworkwithyoutodecidewhataddi*onaltestsorfollow-upcareisneededtoaddressthisissueandkeepyouwell.Some*mesawork-upinvolves:
• Answeringques*onsaboutyourhealthhistory,includinganyobserva*onsyoumighthaveaboutyourmemoryorthinking
• Medica*onreview• Performingbloodteststoseeifyouhaveashortageofcertainvitaminsornutrientsinyourbodythatcouldbecausingchangesinyourmemoryorthinking
• Comple*nganx-rayofyourheadsothedoctorcantakeacloserlookathowyourbrainisdoing 49
Q&A
• DoyouthinkIhavedemen*a/Alzheimer’sdisease?– Thetoolweusedtodaydoesnottelluswhatiscausingaperson’smemorydifficul*esandcannotbeusedtodiagnosedemen*a/Alzheimer’sdisease.
– Therearemanyreasonswhysomeonemightbeexperiencingtroublewiththeirmemory.TheymaynotbegeXngadequatesleepatnightormightbeunderalotofstressorbedepressed.Othercausesincludemedica*onsideeffects,medicalproblemslikeaninfec*oninthebody,andvitamindeficiencies.
– Notallmemoryproblemsarecausedbydemen*a/Alzheimer’sdisease.But,itisimportanttoseeadoctorsowecaniden*fythecauseandfindoutwhat,ifany,treatmentmightbeneeded.
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Q&A
• MyfamilycomplainsaboutmymemorybutIdonothaveaproblem.Everyonemyageisalibleforgezul.– Youarerightthatalotofpeopleexperiencememorychangesastheygetolder.Howmuchvariesfrompersontoperson.Weallwanttostayashealthyaspossibleandmaintainourindependenceaslongaspossible.Havingabraincheck-upisapartofstayinghealthy(andmightbeagoodwaytoshowyourfamilythereisnothingwrongwithyou-toputthisissuetorestonceandforall).
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Q&A
• IthinkIamdoingfine.WhyshouldIseeadoctor?– Itisimportanttocheckthehealthofthebrainaswegetolder,justlikewerou*nelycheckonthehealthofotherorgans,suchastheheart.Some*mes,memorydifficul*escanbereversedwithtreatment.Inothercases,earlydiagnosisofaproblemoffersthebestchancetotreatsymptomsandstaywell.
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Demen*aCareCoordina*on
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ACTPrac*ceTool
Demen*aCarePlanChecklist
Demen*aCarePlanning
• Buildacareteam(pa*ent&carepartners)
• Educate,support&connecttoresources• Maximizeabili*es• Promotehealth,wellness&socialengagement
• Encourageplanning,preparedness• Ensuresafety• Reduceexcessdisability• Avoidunnecessaryhospitaliza*on
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Iden*fyCarePartner(s)
• Educatethepa*ent:Demen*adx.requireateamapproach
• Askthepa*enttoiden*fyasupportsystem– Thinkoutsidethebox:
• Family,friends,neighbors,religiouscongrega*onmembers,colleagues,communityorganiza*onvolunteersorworkers
– Taskspecific(e.g.,doctorvisits,managingmeds.)
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DiseaseEduca*on
• ASKthepa*ent/carepartner:! Whatthedoctortoldthemabouttheirmemoryloss/diagnosis
! Whattheyknowaboutthedisease/ques*onsaboutthediagnosis/disease
! Biggestconcerns;barrierstocare/health• Refertocommunityagency
– Example:Alzheimer’sAssocia*on• Offeraneduca*onalresource
– Example:TakingAc*onworkbook
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Taking Action Workbook
! Understandingthedisease! Partneringwithdoctors! Tellingothersaboutthe
diagnosis! Strategiesformanaging
symptoms&coping! Safety! Legal/financialissues
hbp://www.alz.org/mnnd/documents/15_ALZ_Taking_Ac*on_Workbook.pdf
Medica*onTherapy&Management
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• DiscussprescribedandOTCmedica*ons! Create&reviewmedica*onlog! PharmDconsult:simplifymedica*onregimen
• Createplanwithcareteam! Familyplanformanagingmeds! Medmanagementaids(pillboxes,alarms)
MaximizeAbili*es
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• IDcondi*onsthatmayworsensymptomsorleadtopooroutcomes! Diabetes,HTN,sleepdysregula*on
• RecommendOTtomaximizeindependence! Simplifyenvironment,maximizeindependence&self-care
abili*es
• Offerstrategiestoreducebehavioralsymptoms! Communica*onstrategies,wellness&socialengagement,
rou*ne
CommonDemen*a-RelatedBehaviors• Repea*ng• Anger,Anxiety,Agita*on• Day*mesleeping/night-*mewakefulness• Wandering,Pacing,Shadowing• Apathy• Resis*ngCare• Aggression(yelling,hiXng,bi*ng)• Sociallyinappropriatebehaviors(e.g.,thingsthatmaybeokinprivate,butnotinpublic–likedisrobing)
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CausesofChallengingBehaviors
• PhysicalHealth(Medical)! Pain! UrinaryTractInfec*on! Illness
• Environment! Unfamiliarsurroundings/environment! Over/unders*mula*on
• Other! Communica*on! Unmetneeds/boredom! Task-related! Emo*onalhealth
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ReduceBehavioralSymptoms• REMEMBER:
– Behavioriscommunica*on– Communica*onimpactsbehavior
• Thinklikeabehavioralanalyst– Detec*vework,ask:
• Who(isinvolved/present)• What(exactdescrip*on,bespecific)• When(*medependent?onlyinmorning?triggers?)• Where(loca*onspecific?)• Why(whathappensrightbefore,rightakerwards?whatdofamilythinkiscause?Hasanythingchangedrecently?)
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Considera*ons
• Ask:Isthisbehaviorreallyaproblem?– Isithur*nganyone?
• Helpcarepartnersknowwhattoexpectandnormalizethesereac*ons.– Avoid:unrealis*c,non-demen*aexpecta*ons,arguing,correc*ng,rushing
– Advise:Takeadeepbreath,slowdown,stepback,simplify,smile,redirect,reassure,tryagainlater
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CaregiverSupport
• Thereisastrongcorrela*onbetweenthehealthandwell-beingofacarepartnerandthequalityofcarethathe/shecanprovide.
• Recommend:– Supportgroups– Selfcare,respite– Regulardoctorappointments
Health,Wellness&Engagement
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Encouragelifestylechangesthatmayreducediseasesymptomsorslowprogression
! Exercise! Nutri*on! Stressreduc*on! Meaning&purpose! Rela*onships! Healthmanagement! Rou*ne
www.alz.org/mnnd/documents/15_ALZ_Living_Well_Workbook_Web.pdf
Home&PersonalSafety
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• Developaplanforthe6 F’s:! Falls ! Fire! Finances ! Firearms! Freedom ! Freeways
Home&PersonalSafety
• RecommendOTorPT! Fallriskassessment! Sensory/mobilityaids! Homesafetyinspec*on/modifica*ons! Drivingevalua*on
• EncourageMedicAlert®SafeReturn®" 6outof10peoplewithdemen.awillwanderat
somepointduringthedisease" www.alz.org/care/demen*a-medic-alert-safe-
return.asp
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Demen*a&Hospitaliza*on
• ReduceUnnecessaryHospitaliza*on– Falls– UTI/othermedicalcondi*ons– Medica*ons/medica*onmismanagement
– Demen*a-relatedbehavior– Hospitaliza*onalterna*ves
• Hospitaliza*on–Pre-Planning– hbp://www.nia.nih.gov/alzheimers/publica*on/hospitaliza*on-happens
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Legal&FinancialPlanning
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• Encouragepa*ent/carepartnertoassigndurablePOA! RefertoElderlawaborney
• Encouragepa*ent/carepartnerstotalkaboutlong-termcareandwhentheywouldaccesssupport! hbp://www.alz.org/i-have-alz/downloads/
worksheet_financial_legal.pdf
AdvanceCarePlanning
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• Encouragepa*enttodiscuss/documentpreferencesforcareinahealthcaredirec*ves! Connectpa*entwithadvancecareplanning
facilitator! Documentchoices(HonoringChoices,MN
HealthcareDirec*ve)
• Discusspallia*veandhospiceop*ons! Pallia*veCareConsulta*onProgram! Whenistheright+me?
CareCoordinator:VisitFrequency&Communica*on
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• Scheduleregularcheck-ins
• Educatepa*ent/carepartnerWHENtocontactyou! Changeincondi*on! Assistancewithmedmanagement! Before/akerhospitaliza*on! Changeinlivingenvironment! Newneeds
Top5ResourcesforPa*entsandFamilies
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#1 Promo*ngWellness& Func*on
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#2 AddressingBehavioral Challenges
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#3:AddressingDriving
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Alzheimer’sAssocia*onDrivingCenter:www.alz.org/care/alzheimers-demen*a-and-driving.asp
hbp://www.theharzord.com/sites/theharzord/files/at-the-crossroads-2012.pdf
#4 PlanningfortheFuture
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#5 Connec*ontoResources
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Alzheimer’sAssocia*on24/7Helpline|800.272.3900www.alz.org/mnnd
SeniorLinkAgeLine
800-333-2433www.minnesotahelp.info
Ques*ons?
• DownloadACTonAlzheimer’sprac*cetoolsat:www.ACTonALZ.org/provider-prac*ce-tools
• Formoreinforma*on– email:[email protected]– Web:www.ACTonALZ.org
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Acknowledgements
Authors/Presenters: TerryR.Barclay,Ph.D.Co-Chair,HealthcareLeadershipGroupACTonAlzheimer’s
MichelleBarclay,M.A.Execu*veCo-LeadACTonAlzheimer’s
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ACKNOWLEDGEMENTS
ThistrainingwasmadepossiblethroughtheCentralMinnesotaCouncilonAginginpartnershipwithACTonAlzheimer’s,theMinnesotaGerontologicalSociety,theMinnesotaMedicalDirectorsAssocia*onandtheMinnesotaRuralHealthAssocia*onthroughfunding
fromtheOlderAmericansActandCentraCareHealthFounda*on.
ACTonAlzheimer’sisanaward-winning,na*onallyrecognized,volunteer-drivencollabora*veseekingtocreatesuppor*veenvironmentsforeveryonetouchedby
Alzheimer’sdiseaseandtoprepareMinnesotaforitsimpacts.
Visitwww.actonalz.org/provider-prac*ce-toolsformoreinforma*onandtoaccesssuppor*vetoolsand
resources.
ACKNOWLEDGEMENTS
Thisprojectis/wassupportedbyfundsfromtheBureauofHealthProfessions(BHPr),HealthResourcesandServicesAdministra*on(HRSA),DepartmentofHealthandHumanServices(DHHS)underGrantNumberUB4HP19196totheMinnesotaAreaGeriatricEduca*onCenter(MAGEC)for$2,192,192(7/1/2010—6/30/2015).Thisinforma*onorcontentandconclusionsarethoseofthe
authorandshouldnotbeconstruedastheofficialposi*onorpolicyof,norshouldanyendorsementsbeinferredbytheBHPr,HRSA,DHHSortheU.S.Government.
MinnesotaAreaGeriatricEduca*onCenter(MAGEC)
Grant#UB4HP19196Director:RobertL.Kane,MD
AssociateDirector:PatriciaA.Schommer,MA