Model: Initiating Family with Member Who Has Dementia

I. Initial Contact A. Marketing B. Identified phone C. Response to requests for appointments 1. Dementia identified 2. Dementia not identified II. Initial Visit A. Role of Counseling and Family Sciences Medical

Family Therapist (CFSMFT)

B. Additional members of the support C. Guiding patient and family through the maze D. Providing information 1. Being certain that patient and family are not overwhelmed 2. Information that can be taken home 3. Establish a means by which patient and family can call to clarify, get support, etc. E. Appropriate patient work-up 1. Medicalgeriatrician a)General health, other problems b)Other potential causes of dementia 2. Neurological a)Dr. Sherzai b)? Movement disorder Clinician? c)Neuropsychological evaluation d)MRI e)Other testing F. Other 1. Patient evaluation would be done one on one 2. Informing and teaching of patient and family would best be done in groups 3. Physical Medicine and Rehabilitation a)Physical strength b)Coordination c)Fall potential d)Prescriptions to maintain strength 4. Occupational therapy a)Evaluate home
Model: Initiating Patient and Family Care: Dementia 1 ACOS

5. 6. 7.

8.

9.

(1) Fall risks (2) Ability to use wheel chair and other devices b)Inform of assistance available (1) Devices (2) Personnel Nutrition and diet Counseling and Family Services evaluation and treatment plan Social services and identified support structures a)Assess patients fiscal resources and home support b)Transportation needs c)Recreation, games, finding a group, etc., d)Pet therapy e)Music and art Psychology a)Establish relationship b)Appropriate follow-up c)Role of depression Pharmacist a)Review of current medication b)Potential role, advantages and limitations of Rx for Alzheimer s disease

G. Meet with a volunteer 1. Patient with family 2. Pastor (inquires if appropriate to contact their pastor and bring the services of their church into action H. Follow-up visit scheduled 1. Patient Care Manager explains and listens to be certain that family and maybe the patient understand what will happen next 2. Care Manager keeps contact a)Reminding of importance of the tests b)Assuring that patient will be able to get to testing sites c)Increasing likelihood of compliance with keep appointments d)Requests permission to contact pastor of patients church III.Role of Pastor A. Pastor to meet with CFSMFT 1. Offer training (training program developed by Carrie and Randall) a) Helps pastor identify the natural history and the potential role of the church b)Pastor to understand patients and familys needs (support, transportation, fiscal) c)Encourage pastor to participate in support and encourage family to participate

Model: Initiating Patient and Family Care: Dementia

ACOS

2. Pastor to know the potential sources of support available and identify those that would be appropriate for his/her parishioners 3. Supports pastor as he/she identifies what the patients church can do B. Consider beginning appropriate support groups at

his/her church

IV. First VisitReceiving the Diagnosis Alzheimers

Disease
B. Dr. Sherzai 1. 2. 3. 4. 5. Explains findings Makes diagnosis Offers hope Offers the support services Encourages to slow/prevent progression of disease process

B. CFSMFT present 1. Support 2. Leaves Dr. Sherzais office, if appropriate, brings patients pastor for what follows C. CFSMFT, ideally with pastor present for most or all of

the following

1. Review and evaluate what patient and family heard of teaching from Dr. Sherzai 2. Listens to questions and concerns 3. Counsels patient to embrace his/her dignity as a precious human being 4. Guides family through near term and toward long term planning 5. Helps family anticipate major problems a)Disruptive behaviors b)Continence issues c)Potential disruption of family dynamics d)Potential disruption of familys priorities 6. Reviews support available 7. Either discusses potential legal issues or points to support for legal issues 8. Encourages patient and family to utilize appropriate support D. Patient visits appropriate support personnel in

Neurology office

Model: Initiating Patient and Family Care: Dementia

ACOS

1. Physical therapist a)Evaluation b)Introduction of services available including potential role of occupational therapy c)Discusses fall prevention, home setting, etc. d)Suggests home visit 2. Nutritionist 3. Counseling and Family Services counselor 4. Pharmacist 5. Determination of role of depression and need for psychiatrists E. Follow-up appointments 1. 2. 3. 4. 5. 6. Medical: as determined by geriatrician Neurological as determined by Dr. Sherzai As patient/family needs, determined by CFSMFT Physical therapy Nutritionist Pastor: a)Home visits, how patient doing, compliance with meds and exercises, etc. b)Does a nurse or therapist need to visit home c)Transportation (1) Is patient a safe driver, time to give up drivers
license?

(2) Does patient need help with transportation 7. Additional consultations V. Goals A. Patient and family to grow in the ability to love despite

the impairment B. Family to increasingly see patient as precious and maintain the patients dignity in all situations C. Patient and family increasingly support each other with their individual needs D. Family to identify potential family problems/crises and develop plans
1. To avoid the problems/crises 2. To manage the problems/crises without harm to the family dynamics E. Family make appropriate plans for continuing family

dynamics including
1. Celebrations 2. Holidays

Model: Initiating Patient and Family Care: Dementia

ACOS

3. Vacations 4. Travel 5. Subsequent generations and how they will deal with the patient as a loved member of the family with full rights and considerations F. Church community 1. Embrace their impaired members, including those with dementia 2. Expiate stigmatization, ostracizing, ignoring patients and familys needs 3. Become an advocate for those with special needs 4. Initiate and become an integral part of support systems for those with special needs, parishioners and larger community 5. Members talk with friends and neighbors inviting them to actively minister to those with special needs G. Business community 1. Provide leadership for and actively support those with special needs, i.e., going the second mile 2. Understand that family members have unusual demands so that patients can meet clinical appointments 3. Provide services so that a non-disruptive patient can be brought into the work environment for a short time prior to being taken to a clinical appointment

Model: Initiating Patient and Family Care: Dementia

ACOS