Integrated Memory Care Clinic: Design, Implementation, and Initial Results

The Integrated Memory Care Clinic (IMCC) is a patient‐centered medical homeas defined by the National Committee for Quality Assurance directed by advanced practice registered nurses(APRNs) caring for persons living with dementia (PLWD); physicians provide specialty consultation but do not direct care or care planning. The IMCC incorporates geriatricnursing, social work, and APRNs from neurology, gerontology, palliative care, and geriatric psychiatry. APRNs provide comprehensive, coordinated primary care for dementia, other chronic conditions, and minor acute illnesses. Partnering with PLWD and families and taking a palliative‐oriented, dementia‐informed medical homeapproach, the IMCC aims to reduce dementia burden. This study describes the first 12 months of IMCC's operation with 139 enrolled PLWD‐caregiver dyads. All patients have a diagnosis of dementia or mild cognitive impairment; most have Alzheimer's disease (53.2%). Patients have an average of 5.8 medical conditions and 6.9 prescriptions; 38.1% have an advanced directive, a medical powerof attorney, or a living will. Mean age is 78.6, 63.3% are female, and 30.9% are African American. Mean Montreal Cognitive Assessmentscore is 12.6. Most require assistance in activities of daily living. Many display neuropsychiatric symptoms. The most prevalent comorbidities are hypertension, dyslipidemia, and depression. The rate of ambulatory‐sensitive hospitalizations declined from 6.7% in December 2015 to less than 1% in May 2016. Caregivers were highly satisfied. We observed nonsignificant improvements in neuropsychiatric symptom severity (p=.07), caregiver distress (p=.69), and caregiver competence (p=.18). IMCC is a novel care model for PLWD and their caregivers and may be a more sustainable model than traditional primary care for this growing vulnerable population. J Am GeriatrSoc 66:2401–2407, 2018.