Memory Loss Program

Community Cares for you dec 2014MEMORY LOSS PROGRAM REFERRAL FORM CLICK HERE!

Community Nurse’s Memory Loss Program provides both in-home and community based programs for patients and families within our service area with a memory loss diagnosis, like dementia and Alzheimer’s Disease, regardless of their individual financial resources.

With a generous founding gift from a local charitable organization, Community Nurse developed the Memory Loss Programs to provide support and respite through Home Health Aide services for the patients and their families who are most vulnerable, at risk and with financial limitations.  All of our Home Health Aides were and continue to be trained in caring for a patient with a Memory Loss diagnosis. Aides are assigned to provide personal care to the patient and to provide mental stimulation.

Often a patient with a Memory Loss diagnosis becomes unable to direct their day and as a result suffers from extreme boredom. Activities that used to be enjoyable to them, such as reading or watching television, no longer hold their interest. Our Aides have been trained to successfully engage the patient in activities and conversation. If the patient is capable of playing a simple card game or making a puzzle with assistance from the Aide, these activities are pursued. This service also provides much needed down time for the caregivers on whom these patients become so reliant. Those patients and their caregivers who could not otherwise receive this care due to limited financial resources can apply for funds from our Memory Loss Program Fund. Patients must meet the specific criteria to receive these services.

With the right oversight, ongoing funding and expertise, this program has grown to a comprehensive Memory Loss Program that improves the patient’s overall quality of life and provides important support to those who through their role as caregiver suffer physically, emotionally and mentally. In addition to Home Health Aides the program has evolved and now consists of a Program Manager (RN), Social Workers, Psych Nurses, LPNs, a Marketing Liaison, Care Transitional specialists, Volunteers, Homemakers, Occupational Therapists, Physical Therapists and Complementary Therapy practitioners.

The program provides assessment, education, caregiver support, care navigation/planning, resource assistance, respite, counseling, occupational therapy, complementary therapy, an inter-disciplinary team approach/care and a 24 hour helpline. Through early referral and comprehensive case management, in home and community care, educational materials, volunteer respite care, collaborations with community partners, physician referrals, the creation of full documentation and community outreach the patients and caregivers in our community have come to rely on these services.  

Community Nurse is the only comprehensive Memory Loss Program in our area. Our Memory Loss Program is well known in the community. Our reputation is strong and the demand is only growing. Anyone can make a referral for an assessment and we receive many referrals directly from families, physician offices, hospitals, community partners, peer home care agencies, local Councils on Aging and grateful patients. With over 120,000 living with memory loss in Massachusetts in 2014 and a forecasted increase of 25% by 2025, the future of these programs are essential to those people in this community who face a memory loss diagnosis.

Too many of have been touched by memory loss illnesses. A diagnosis of a Memory Loss illness can be a scary for both the patient and their family. Not only is the patient facing uncertainty with their illness but medical information is coming to them from various different members of their care team: physicians, nurses, aides, therapists and even dietitians After discharge they will have follow up appointments with primary care physician and specialists. Often the familiar medications are changed or new unfamiliar medications are prescribed. As the disease progresses things become more and more unfamiliar, confusing and, at times, frightening. We offer support groups for caregivers in towns that request it throughout our service area.We want to provide guidance and support to our patients and their caregivers as early as possible and throughout their journey.

Our Program Manager (RN) makes assessment visits in the community. A plan of care will be established following the assessment visit. The needs of our patients will vary depending on how progressive their illness is. Some patients may only require Home Health Aide services at admission due to their state of health while others will need more skilled services initially for teaching and home safety evaluation.

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An initial visit is paid to the patient’s home to assess the families’ situation, establish rapport and make a true evaluation of the patient condition in their own environment. During this initial visit the caregiver’s needs are established and how they are managing with the caretaking role is evaluated.

Obstacles, barriers, shortfalls and needs are often brought to light during this initial visit such as lack of health insurance, limited financial means, language barriers, emotional/mental strains, custodial and safety concerns. Our staff then introduces the family to appropriate services through Community Nurse.

For example, an occupational therapist from Community Nurse can oversee the installation of adaptive equipment like a shower seat, a bilingual social worker can visit the house to meet with the patient and their caregivers, Community Nurse home health aides and homemakers can make regular visits to help with personal and home upkeep and support groups for caregivers hosted by Community Nurse staff and attended by families in like situations are introduced. The family is also connected to appropriate external resources like Adult Day Health for specialized care during work hours and Coastline to help secure Mass Health insurance. Known to wander, as many people with a Memory Loss diagnosis do, families can also linked to the Alzheimer Association’s safe return program.evaluation of the patient condition in their own environment. During this initial visit the caregiver’s needs are established and how they are managing with the caretaking role is evaluated. Obstacles, barriers, shortfalls and needs are often brought to light during this initial visit such as lack of health

There will be ongoing visits by a Registered Nurse to supervise and reassess the patient’s condition. The plan of care will be updated as needed. Life typically becomes more manageable with the added resources both in the home and in the community. And a 24 hour hotline is always whenever there are questions or additional support is needed. As the disease progresses, many of our Memory Loss patient become hospice eligible. It was a comfort to families that many of the staff and volunteers who had already been involved in the patients care are a part of her inter-disciplinary course of hospice care.

Our programs continue to grow. We consistently pursue the latest training opportunities for our Program Manager (RN) and clinical staff. And we have made a commitment to train our general staff and volunteers in the latest methods and approaches to Memory Loss Care. We are looking to grow our Complementary Therapy offerings with music, massage, art and multi-generational activities. We have a lending library and hope to create a Memory Loss specific booklet (similar to our existing chronic disease booklets).