Alzheimers Disease in the Frontier: The Use of Telehealth for Dementia Care in Rural Nevada

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Alzheimers Disease in the Frontier The Use of
Telehealth for Dementia Care in Rural Nevada
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Lisa Dinwiddie MS, RNCornerstone Care
Consultants, Elko, NV

• Debra Fredericks PhD, RNC, APN
• Patty Charles DrPH,MPH
• University of Nevada, School of Medicine, Reno,
  NV
• Charles Bernick MD
• Lou Ruvo Brian Institute, Las Vegas, NV
• Sylvia Elexpuru BSN, RN
• BrightPath Adult Enrichment Center, Elko, NV
• Gerald Ackerman, MS,
• University of Nevada, AHEC, Elko, NV

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Road from Elko to Lamoille.  Snow covered Ruby
Mountains are in the distance.
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Nevadas Demographic

• Nevada has had one of the highest percentage
  increases in its senior population in the nation
  between 1990 and 2001 the total population of
  Nevada grew by 70, while the 50 population grew
  bygt100.
• In rural Nevada, 13 of residents are over the
  age of 65
• Projections estimate a 100 increase in the
  number of Nevada residents with AD but a rural
  increase of gt 150 by 2016.
• Service delivery is particularly challenging in
  rural Nevada because of substantial geographic
  barriers separating isolated rural communities
  and a scarcity of rural providers.

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Rural Nevada

• Nevada is the seventh largest State and the 8th
  most rural, with an average of 22 person per
  square mile.
• Only Clark County (Las Vegas), Washoe (Reno) and
  Carson City (the Capitol) have more than 60
  persons per square mile and are classified as
  urban by the Census.
• Seven of Nevadas 17 counties have fewer than 2
  persons / sq. mile.
• Nevada also has a significantly diverse senior
  population. In 2006, the Census reported that
  Nevada has the 5th highest of Hispanics (at
  22.8), trailing only New Mexico, California,
  Texas and Arizona.

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Program Overview

• 1994 opened Las Vegas Alzheimers clinic with
  IIIB grant from Division for Aging Services (MD)
• 1996 Reno clinic opened (PhD/APN)
• 2000 Elko Pilot Clinic ( MD flown in)(RN)
• 2001 Elko Clinic began transition to telehealth
  program
• 2006 Full transition to telehealth program with
  
• HRSA grant award
• Services
• Diagnosis and Medical Management
• Social Service Referral
• Competency Evaluations
• Case Management/Future Planning
• Behavioral Consultation and Counseling for
  individuals and families

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University of Nevada School of Medicine
Compressed Video Sites
ELKO
RENO
LAS VEGAS
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Elko Telehealth Clinic 2001-2005

• Clinic Schedules
• Started with 2 Monday clinics with neurologist a
  month (2 hrs)
• Added 2-5 Thursday clinics with APN for f/u and
  behavioral assessments (2.5hrs)
• Procedure for Diagnostic Service
• Initial evaluation is conducted by nurse
• Screening inventories completed prior to appt.
• The neurologist validates the diagnosis
• F/U care is with nurse practitioner
• Elko nurse also meets with family and/or patient
  for repeat measures, counseling, social service
  referrals , case management, etc

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Impetus for Telehealth Expansion

• Expand clinic services
• Telehealth patients commuting gt 150 miles to the
  Elko Clinic
• Need for IAV equipment at physician offices
• Introduce Education and Support Services
• Lack of consistent AD education for caregivers
  and professionals
• Need to organize a local support group
• Question Raised?
• If the T1 lines and IAV equipment are available
  in other more remote sites, why cant we see
  patients in their own communities?

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Goals

• To provide Excellent patient/family care services
• To keep dementia patients independent/ out of
  long term care facilities as long as possible
• To provide quick turn around time for
  appointments
• To demonstrate that telehealth Alzheimers Clinic
  to be a viable and important member of the
  medical community ( continuity of care).
• Positively impact caregiving in the rurals
• Being a presence in lives of community members
  and in extended care facilities

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HRSA Partner Buy in and Support

• To partner was a natural progression
• All partners were currently working together in
  some capacity
• Patty Charles, UNSOM recruited for the evaluation
  piece
• Expansion Plan to other rural/frontier towns
• 1. Start with education for caregivers and
  professional
• 2. Implement clinics where current patients live
  
• Year 1 Battle Mountain, Eureka, Yerington,
  either Ely, West Wendover, or
• Winnemucca
• Year 2 2 more rural sites central Nevada
• Year 3 Native American, minority communities in
  Nevada and out of state

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Training and Implementation-Clinics

• CCC contracted with local hospitals to provide
  site tech and clinic support
• CCC provided onsite training with training packet
  plus Medicare telemedicine billing instructions
• CCC attended first hook up at rural sites.
• Have trained techs in Battle Mountain, Eureka,
  Ely, Yerington and Winnemucca
• Training and Implementation- Classes
• Set up caregiver class schedule every other month
• Personally invited families in clinic, fliers to
  other sites
• Set up professional classes opposite months- AHEC
• Made fliers sent to appropriate agencies

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Education Classes

• Started in Nevada
• Year 2 expanded education services to caregivers
  and professionals in rural Oklahoma- HRSA grantee
  contact
• Partner with Alzheimers Association and take
  classes on the road. Great for buy-in and
  marketing.
• Year 3 Looking to expand to Casper, Wyoming (
  patient has moved there)
• Interest in expanding toother rural/frontier
  states.

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Challenges

• Local physician support. Positive patient report
  helped. Now have 4 local physicians who routinely
  refer.
• Keeping it all running smoothly. Increasing the
  sites increases the work exponentially.
• Funds for travel and more staff
• UNSOM
• IAV equipment hard of hearing patients
• Every frontier community has its own personality

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Program Supporters

• Referrals came from
• Word of mouth
• DAS, EPS
• Public Guardian
• Adult Day Care/ long term care facility
• Local physician
• Patient satisfaction with both clinics and
  classes
• Georgia Health Policy Center Karen Wakeford and
  Eileen Holloran
• Professional satisfaction with classes and
  consults
• AHEC

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Successes/Best Practices

• Excellent integrated services provided.
• Provided services in communities that were
  unplanned (Ok).
• Evaluations from clinicians, patient/caregivers,
  class attendees have been invaluable. Start
  evaluation process right away.
• We are meeting the goals with ideas for expanding
  services to include psychiatric care
• Sustainability will come through the Lou Ruvo
  Brain Institute.
• Basic understanding of best use of IAV system.

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Tips

• Be sold on your program- enthusiasm sells.
• Evaluate what you are doing and fix the problems.
• Expect the unexpected.
• Keep in close contact with partners.
• Keep on task. Do what you say you are going to
  do.
• Market , market, market to potential funders.

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Contact Information

• Lisa Dinwiddie MS, RN 775-738-8411/
  775-934-3468, fax [phone]
  cstonehm_at_frontiernet.net P.O. Box 279 Elko, NV
  89803. Program Coordinator
• Sylvia Elexpuru BSN,RN 775-934-5704 Grant
  administration, esap1_at_frontiernet.net
• Gerald Ackerman MS, Director University of Nevada
  AHEC, Elko NV. 775-738-32828 gackerman_at_medicine.ne
  vada.edu
• Charles Bernick MD, Lou Ruvo Brain Institute
• Debra Fredericks PhD, RNC,APN, 775-322-2731,
  dfredericks_at_medicine.nevada.edu

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