Transitioning an in‐person geriatric memory clinic to a virtual care model for rural primary care clinics

Dementia is a leading cause of disability and dependency among older adults, with an estimated 6.2 million Americans affected in 2021 and $355 billion in direct care costs.1 Experts recommend management of less-complex patients in primary care and more complex patients by geriatricians.2-4 However, shortages in the geriatric workforce make access challenging, particularly in rural communities.5 Virtual care via video conferencing is a promising strategy for addressing specialist shortages while improving access.6-8 These models have been examined in select populations including veterans,9 but have not been studied using a team-based approach. Our memory clinic located in the Charlotte metropolitan region is a geriatrician-led, team-based clinic dedicated to diagnosis and management of dementias.8 Our prior research identified several program strengths, including the team-based approach to enhance care coordination and education. Here, we describe how we expanded our in-person memory care model through telehealth to improve access for patients living in rural settings. We partnered with two rural primary care clinics in Stanly and Cleveland counties (North Carolina), each with high numbers of patients aged 65 years and older (based on prior year visits). At each facility, we embedded the virtual memory clinic (VMC) into the primary care workflow. We adapted each component of our in-person clinic to accommodate virtual delivery of this tailored dementia screening and referral program (Figure 1). Our model leveraged existing patient–primary care provider (PCP) relationships along with centralized electronic medical records (EMR) and billing and scheduling systems shared across primary care sites and memory clinic locations. Patients were eligible for referral if their PCP suspected potential or existing memory issues. No prior formal memory screening was required. Virtual visit costs were covered by extramural funds. This program was deemed Quality Improvement by the Atrium Health Institutional Review Board. Our VMC model followed a protocolized approach. At initial visit, the local primary care practice's Medical Assistant (MA) roomed the patient and caregiver(s) off camera to collect basic information, vitals, and reconcile medications. The caregiver met independently with the geriatrician and social worker, via telehealth technology, to discuss the patient's condition and cognitive history while the MA completed the Montreal Cognitive Assessment and depression screening with the patient and shared results via the EMR for geriatrician review. Screening results were discussed with the caregiver along with educational resources and caregiver/respite care options. Next, the patient joined the telehealth room while the geriatrician reviewed disease history, screening results, medications, and nonpharmacologic interventions for memory. At visit completion, the MA provided a summary of tips and resources, medication changes, and follow up instructions (Figure 2). Within 1 week of the virtual visit, the navigator followed-up via phone with the caregiver to address remaining questions. Caregivers also received a satisfaction survey through text message. The navigator continued monthly phone follow-up with caregivers, focusing on advanced care planning, while the geriatrician followed-up virtually at least every 6 months. The VMC saw 115 patients, of whom 70.4% (n = 81) had never seen a specialist for memory loss issues and 87.0% (n = 100) were diagnosed with some level of cognitive impairment (mild cognitive impairment [MoCA = 18–25] 22.6%, mild/moderate dementia [MoCA = 11–17] 47.9%, moderate severe/severe dementia [MoCA ≤ 10] 16.5%). Among the 105 caregivers who answered the satisfaction survey, 93.3% would choose to use the VMC services again and 95.2% would recommend these services to others. Satisfaction surveys were administered to the 18 providers with patients eligible for VMC, with a response rate of 33.3% (n = 6). One respondent did not refer any patients because the referral process was too complicated. The other 5 respondents all strongly agree that they would refer their patients to the program again and would recommend the services to their colleagues. They also expressed that VMC is a great service, particularly with the length of time spent with the patient/caregiver. Despite implementation challenges (Table 1), we successfully translated all elements of the in-person memory clinic into virtual delivery via primary care. In addition to convenient, virtual access to a geriatrician, patients benefited from the continuity of having their cognitive screenings performed by familiar primary care staff. Caregivers received monthly phone calls from the navigator to build rapport, solicit questions, and provide non-pharmacologic interventions and resources. Like our in-person clinic, patients and caregivers shared that education and support facilitated by the navigator was a meaningful and valuable component of the VMC experience.10 PCPs also benefitted from VMC support in managing multiple aspects of routine care (e.g., caregiver education, advanced care planning, driving safety evaluation, dementia-related behavioral management, and reduced triage communication for behavioral issues). Designated site-based medical assistants (MAs) trained to administer: Strategies to improve engagement with site providers: Provider engagement and patient recruitment Lessons learned: COVID-19 pandemic Site-based structure and scheduling Barriers: Lessons learned: Our results support the feasibility of virtual team-based dementia care for improving access to care addressing the clinical and psychosocial needs of patients and caregivers. Scaling this model requires addressing implementation challenges in collaboration with stakeholders, tailoring content, and securing funding. Reimbursement for virtual visits precipitated by the COVID-19 pandemic hold promise for virtual care as a viable option for dementia care into the future. The authors of this article would like to acknowledge the participating clinics, including clinic staff, medical assistants, and primary care providers who helped with the implementation of the virtual memory clinic. It was a privilege to collaborate with the participating clinics. We also thank Dr. Marc Kowalkowski for providing critical feedback on the manuscript. All authors received no support from any organization for the submitted work, have no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years, and have no other relationships or activities that could appear to have influenced the submitted work. All authors contributed to the design and execution of the virtual memory clinic implementation. Tsai-Ling Liu drafted the manuscript; all coauthors provided intellectual content, critical revisions, and approval of the final draft. Sponsors had no role in the design, methods, subject recruitment, data collections, analysis, or preparation of the paper. Table S1 List of patient resources provided at the memory clinic and VMC. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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