Franciscan Skemp Healthcare Dementia Care Program

The Dementia Care Program is a coordinated, multidiscipline programmatic approach to the dementia patient. The program was started in 1997 with the goal of improving the diagnosis, treatment, and long-term follow-up care of the dementia patient and dementia associated problems that can occur. A computer database is also maintained for data and information collection that will be used to further expand the knowledge about dementia, how it impacts the local community, and what interventions are effective in maintaining the patients at home with a good quality of life. The multidisciplinary team meets to review and discuss the status of Dementia Care Program patients, especially those patients that are at high risk of needing extra assistance or close monitoring. Family support and education are also provided.

Participants and Their Roles

Franciscan Skemp Healthcare

Department of Geriatrics:

Medical evaluation and diagnosis

Long-term follow-up

Database

Coordination of care

Medical care of nursing home patients

Dementia education coordination for patients, families, communities, nursing home staffs, etc.

Support Groups for individuals with early memory loss, mid-stage memory loss and a group for their families

Training for staff

Interaction/coordination with the Alzheimer's Association, Riverland Chapter

Elder Services:

Social service assessments

Advanced care planning

Community resources

Senior housing

Lifeline

Senior Helpline

Education

Department of Behavioral Health/Neurology:

Neuropsychological evaluation

Long-term follow-up

Education

Counseling of patients and caregivers on an as-needed basis

Alzheimer's Association, Riverland Chapter:

Education for patients, families, community

Support groups

Program volunteer training and coordination

The initial visit takes approximately one hour. The Geriatrics team will gather a detailed history of the patients symptoms and medical background. We encourage patients to have a family member or friend accompany them to their appointments.

At the conclusion of the first visit a treatment plan is developed with the patient and family. The treatment plan varies based on individual needs, but often will include referral for neuropsychiatric testing, and lab work.

After completion of testing the patient will return to the department of Geriatrics where the results of their testing will be discussed and further treatment planning will occur. At this time patients and families can receive education, information and referral to community resources, assistance with Advance Directives, etc.

Follow-up Protocol

Patients starting or changing medications are seen monthly until stabilized. They are then seen for routine follow-up visits every 6 months. Each year the patient will be tested with a follow-up neuropsychology test and the database is updated. Patients will be seen sooner if needed. Assistance to patients and families is provided on an ongoing basis by connecting them with community services and educational resources. Routine telephone follow-up will also be made.

Wisconsin Alzheimer's Institute

The role of the WAI will be to coordinate the database collection for the state-wide system of diagnostic clinics, assist with data analysis for publications and serve as a resource for Alzheimer’s and related dementia. If needed, the WAI will also assist with the interactions of the Program with the Alzheimer’s Association chapters.

Conclusions

Franciscan Skemp Healthcare’s Dementia Care Program, in conjunction with the opportunities afforded with participation in the WAI’s state-wide system of clinics, will provide state-of the-art diagnostic and treatment planning for dementia patients in the La Crosse area. We will be expanding the Dementia Care Program throughout the rural tri-state regional service area of La Crosse through the Geriatric Medicine outreach service to the regional clinics and nursing homes.

For more information, or to make an appointment, please contact:

Dementia Care Program
Franciscan Skemp Healthcare
Thomas Loepfe, MD, Director
800 West Ave. S.
La Crosse, WI 54601-4700
608-791-9505
www.franciscanskemp.org

Return to list of WAI-Affiliated Dementia Diagnostic Clinics