Raising the Bar for Memory Care

In Atlanta, Georgia, there is a nurse-led primary care clinic specializing in memory care. This may sound too good to be true, but for the nurses leading this work and the patients receiving care—it’s real life and deeply meaningful.

Emory Healthcare’s Integrated Memory Care (IMC) Clinic is the only primary care practice in the U.S. specifically made for people living with dementia. Despite its cutting-edge approach, Emory recognized it needed to better address the unique challenges and needs of patients and their families, so it expanded its services beyond the clinic walls.

With support from the American Nurses Foundation’s Reimagining Nursing Initiative, Emory brings its specialized and patient-centered approach directly to the people who need it. The Initiative-funded project Integrated Memory Care in Community (IMCiC) focuses on providing high-quality, comprehensive care for residents in senior living communities. This model allows Emory to care for multiple patients in the comfort of their homes.

But that’s only part of what makes IMCiC groundbreaking. They are keenly aware of the immense pressure of caring for a loved one so the project is also designed with caregivers in mind.
For Cotenna Clark, the project’s adult geriatric nurse practitioner, caregivers are what she calls the “sandwich generation”—a group of people raising children and caring for their aging parents at the same time. Cotenna says “IMCiC provides a sense of freedom and relief for caregivers because it relieves them of the difficulty of getting their loved ones into a clinic to be seen.”

Meeting Families Where They Are

It seems simple: nurses go into the home and provide care where patients live. But IMCiC’s approach is much more involved than that. The initial visit can include getting lab work and imaging, without patients leaving their homes.

After that, a customizable care plan is created with input from caregivers. A patient will have access to, and frequent contact with, a nurse practitioner, an occupational therapist, and a dementia care assistant—a community health worker with specialized training. The visits occur on the same day and time every week. Cotenna says this structure and consistency are essential to providing high-quality memory care.

Even though visits are scheduled, the IMCiC team can make urgent visits and assess quickly changing situations, keeping caregivers informed and prepared. “There are times I have to call the family with an updated set of recommendations,” Cotenna explained. “I say this is what I am seeing, and this is what you can expect three to six months down the road—it’s a lot of anticipatory guidance as well.”

Building Relationships with Patients and their Families

Oni Anderson grew up an only child. Her mother, Delbra, was a flight attendant for 40 years. But in 2018, Delbra felt something changing within her, Oni recalls. It wasn’t long until she was diagnosed with frontotemporal dementia. Oni was thrust into a new role and became her mother’s caregiver while raising two young children and running a successful business.

Oni says getting her mother the needed care was challenging and often frustrating for Delbra. After connecting with the IMCiC team, Oni noticed a significant change in her mother. “Once they knew who she was, they became very attuned with her,” she said. “They helped regulate some of the lows that come with the diagnosis, like being angry and confused and not really being able to communicate that.”

The IMCiC team collaborates with Oni to ensure her mother gets comprehensive care that addresses her health in a holistic manner. Delbra’s care plan includes day-to-day activities that support her mental health, something Oni says demonstrates the team deeply understands her mother and care about the quality of her life. “Everyone else tells you to just live with this and that there’s nothing you can do about it,” Oni recalls hearing in the early days of her mother’s diagnosis. But IMCiC helped Oni see there was so much more that could be done to support her mother. “They were like ‘Oh, she was a flight attendant; let her push a cart around so she feels like she’s working on an airplane again.’” That activity and other forms of therapy and care helped ease Delbra—proving they didn’t have to just live with dementia, they could thrive.

Collaborating with Caregivers for Added Support

Vivian Bencich had a close relationship with her mother, Lillian, growing up. When her mother was diagnosed with dementia in 2019, Vivian remembers bracing herself for that reality. Vivian’s father had Alzheimer’s disease, and her mother was his caretaker—now Vivian is doing the same for her mother.

But caregiving has changed over the years, and Vivian says she’s getting the help she needs from IMCiC to balance her career, her family, and care for her mother. “It is such a comfort to me and my mom. It’s just the two of us left in our immediate family, so this additional support is so important for us.”

Not only is Vivian getting the support she needs but she’s also learning a lot about dementia and her mother. After each weekly visit, Vivian gets a detailed summary of her mother’s daily activities, social engagement, nighttime behaviors, and overall mood.

The team then lists specific goals based on what they observe. They engage Lilian in cognitive therapy and various other activities—"the level of auditory, tactile, and proprioceptive stimulation helps her so much. Reading through and incorporating their recommendations has been a godsend,” Vivian added.

Vivian says having IMCiC as true partners in her mother’s care allows her and her mother to spend more time together. Recently, they traveled out of state to watch Vivian’s daughter Lily (named after Lilian) graduate from college.

Making a Case for Specialized Care

While many nurses and care teams work in hospitals or clinics, there are other settings where nurses can make a significant impact, and IMCiC is proving that. “There are many ways to practice and make a difference in patients’ lives. Maybe we can help them avoid higher levels of care,” said Alison A. Schlenger, APRN-BC, associate lead nurse practitioner. “People living with dementia do best if they don’t end up in the hospital.”

Alison says paying nurses at the front end of patients’ care, which includes reimbursing nurses for providing health coaching and assessments and empowering caregivers, reduces the cost in the long run and hospital admissions. “Paying for nurse expertise sends the signal that their contribution to a care team is valued by the system,” Alison explained. “If IMCiC can show that this is possible, and we can provide better care and improve outcomes then other practices could open and help care for more people living with dementia.”