School of Nursing Faculty Establishes Emory's First Nurse-led Medical Home

Emory NursingSeptember 28, 2016
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Carolyn Clevenger works work with a patient.

Emory University’s Nell Hodgson Woodruff School of Nursing, Department of Neurology, and the Department of Psychiatry launch the academic health system’s first nurse-led medical home.  The brainchild of Nell Hodgson School of Nursing Assistant Dean for MSN Education Carolyn Clevenger, DNP, RN, GNP-BC, AGPCNP-BC, FAANP and Clinical Nurse Specialist and Alzheimer’s Disease Research Center Administrator Janet Cellar DNP, PMHCNS-BC, the Integrated Memory Care Clinic is the nation’s only practice specializing in primary care for people living with dementia. Earning Level III accreditation, the National Committee for Quality Assurance’s highest ranking for medical homes, clinic nurse practitioners will be eligible to participate in new value-based health care models, scheduled to take effect in 2019. These models reward providers for delivering documented quality care, using resources efficiently, employing practices shown to improve outcomes, and keeping patients out of the Emergency Department.

At a time when there is a shortage of primary care providers, a nurse-led model of primary care offers consumers with limited access to primary care new opportunities to receive high-quality health care. Part of the philosophy of patient-centered medical home model, as the name implies, is putting the patient's health first. The approach seeks to facilitate partnerships among the patient, his or her provider, and the patient’s family. While the concept is not new, the model has evolved to emphasize team-based care and several core components of primary care, including access and availability, patient and family relationships with a consistent practitioner, comprehensive care, and coordination between specialists and community providers.

The idea for the clinic developed through Dr. Clevenger’s work with Dr. Cellar at the Alzheimer’s Disease Research Center, one of only of 27 active centers in the nation supported by the National Institutes of Health. The Center conducts innovative research and provides comprehensive dementia care services for people living with Alzheimer’s and other related diseases. Through the collaborative model, patients and families developed close bonds with their physicians and advanced practice nurses and received excellent disease management care. But patients often came to the center with much more basic primary care needs.

“Patients would often come in with problems that stemmed from medical sources, like a urinary tract infection,” said Dr. Clevenger. “Patients would look sicker than one would expect from something minor like a urinary tract infection, and would sometimes exhibit behavioral symptoms, such as restlessness, pacing, or hallucinations but antibiotic therapy is typically prescribed by primary care rather than a neurologist.”

Patients’ living with Alzheimer’s and other dementias have complex health care needs and families wanted one place where they could receive the broad range of medical and social services their loved ones required.

“What families told us they needed was dementia-sensitive primary care,” said Clevenger. “Everything from pneumonia vaccines, mammograms, or diabetes management, needs to be addressed through the lens of the fact that the person has a degenerative illness that will limit their lifespan.”

Clevenger worked with Alzheimer’s Disease Research Center director Allan Levey, M.D., Ph.D. and a team of other Emory researchers to pursue grant funding for the integrated memory and primary care clinic concept, but the project did not receive funding. Then unexpected gifts from two anonymous donors helped bring the idea of the Integrated Memory Care Clinic to fruition.

In addition to the Department of Neurology, the Integrated Memory Care Clinic also draws upon the expertise of the Emory Palliative Care Center and the Division of General Medicine and Geriatrics, to provide cost-effective, continuity of care in a dementia-sensitive context. Greg Esper, MD, Director of New Care Models, said the clinic is a win-win for patients and families as well as clinicians.

“Our patients receive timely access to the high-quality care that they need and deserve, which greatly improves patient and family satisfaction. They gain the benefit of expanded program and service offerings, which, hopefully, will fulfill the triple aim of value-based care and translate into a lower cost of care for patients,” said Esper.

The clinic’s holistic approach is respectful of where patients are in the balance of their lives and places families at the center of clinical decision-making process.

“To the extent that we can and within the limits of safety, we let patients and families guide their care,” said Clevenger. “I discuss and recommend treatment options, but, ultimately, patients and families decide how aggressively they want us to manage their symptoms. As long as they are making an informed decision, they get to make that decision whether or not I agree with it.”

Through continuous education, planning and shared decision-making, patients and family caregivers directly participate in developing their own unique, personalized care plan. The clinic not provides intensive clinical management of patients’ complex chronic disease but streamlines the care process by coordinating needed services with other community providers.

If patients and families have questions about their care plan or need immediate attention, the Integrated Memory Care Clinics’ nurse practitioners are available 24 hours a day, seven days week. In addition to primary care nurse practitioners, Eve Byrd, MSN, MPH, FNP-C, a nurse practitioner specializing in geriatric psychiatry, helps patients and families understand and cope with the emotional and behavioral challenges associated with the Alzheimer’s and other dementias. The clinic’s registered nurse provides phone triage and guidance when minor health problems arise. Within 48 hours of an office visit, she follows up on any labs, prescriptions, or specialist referrals ordered to answer any questions and to ensure that patients are receiving the care that they need. A clinical social worker coordinates needed supportive care with other aging service providers, such as meal delivery services, transportation, home care agencies, companion services, adult day programs, and assisted living or personal care homes. Since May, the Integrated Memory Clinic coordinated ancillary and community-based aging care services for 139 families.   

Because a diagnosis of Alzheimer's disease affects both patients and their loved ones, the clinic also provides support and educational programs caregivers. Through an evidence-based program, called Savvy Caregiver, co-authored by School of Nursing faculty, Dr. Ken Hepburn, caregivers learn what to expect as the disease progresses and are equipped with the basic knowledge, skills, and attitudes they need to manage their stress and effectively care for someone with Alzheimer’s disease. The Integrated Memory Care Clinic also offers support groups and training programs, such as its Early Memory Loss support group, or its Late-Stage Disease class. More than 20 percent of the caregivers whose loved ones are receiving care at the clinic utilize these services.

Located within Emory’s Memory Disorders Clinic at 12 Executive Park, clinic nurses are accepting patients from both within and outside of the Emory Healthcare system with a diagnosis of Alzheimer’s disease or other type of dementia.