The Department of Veterans Affairs Tennessee Valley Healthcare System (TVHS), is a health care system with 140,000 patients in Middle Tennessee. There are 2 campuses located 40 miles apart, with 20 affiliated community-based outpatient clinics (CBOC’s). An estimated 8,500 dementia patients are cared for at TVHS.
In 2011, TVHS developed a geriatric patient-centered medical home model, the geriatric patient-aligned care team (GeriPACT) [7]. GeriPACT is a special population PACT within primary care for complex geriatric and other high-risk vulnerable veterans providing integrated, interdisciplinary assessment and longitudinal management, and coordination. The practice is supported by the Department of Veterans Affairs Computerized Patients Record System (CPRS), including the electronic patient portal, My healthevet, with telemedicine capabilities. The TVHS population group from 100,000 to 140,000 over a 10-year period.
Since 2018, a geriatrician affiliated with GeriPACT, performed the majority of the dementia consults separate from the primary care geriatrics patient panel care, working through the referring PCP in primary care practices and CBOC’s. Neurology does not have a cognitive clinic at TVHS and limits primary cognitive disorder patients unless also associated with TBI or movement disorders. Psychiatry sees dementia patients with behavioral concerns.
Dementia consultation was initially conceived as an in-person consultation and management service provided by GeriPACT. Access concerns for referral patients led to the development of telehealth capability in 2018 and the dementia clinic transitioned to virtual care in response to the Covid 19 pandemic in 2020. Referrals from primary care providers were often triggered by dementia warning signs such as delirium with acute illness, wondering, self-neglect, need for appointment of a fiduciary, and caregiver concerns about behavioral manifestations and need for support services.
Consults were received electronically, responded to within 48 h, and consisted of a thorough review of the electronic health record and provision of an individualized educational consultation to the primary care provider with specific diagnostic and management recommendations. Primary care providers were requested to perform on-site diagnostic testing when indicated (i.e. thyroid function tests, B12, neuroimaging) and mental status screening. The SLUMS, [8] is preferred at VA as other validated tests such as the MMSE [9] and MOCA [10] have recently been monetized.
In conjunction with the dementia consult clinic, a virtual caregiver support group was initiated, co-facilitated by the geriatrician and Caregiver Support Program social worker [11]. A 4-class weekly curriculum was offered to caregivers and focused on emotional support, caregiving skills and sharing of best practices, as well as generating clinical referrals and supplying equipment needs for veterans. Similar to the dementia clinic, the caregiver support group became entirely virtual in 2020. Caregivers were referred to the support group by primary care providers as well as nurses and social workers caring for PLWD in other settings.
Ethical approval and consent to participate
This study adhered to the Declaration of Helsinki. The Department of Veterans Affairs, Tennessee Valley Healthcare System (TVHS) Institutional Review Board (IRB) has determined this study as a quality improvement initiative and waived informed consent for participants.
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