Integrating AAA Care Coordinators in Primary Care for Dementia Support: Implementation Challenges and Lessons Learned

Mary C. Ehlman (), Suzanne Leahy, Reagan Lawrence and Della Evans
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Mary C. Ehlman: Bronstein Center for Healthy Aging and Wellness, Kinney College of Nursing and Health Professions, University of Southern Indiana, 8600 University Boulevard, Evansville, IN 47712, USA
Suzanne Leahy: Bronstein Center for Healthy Aging and Wellness, Kinney College of Nursing and Health Professions, University of Southern Indiana, 8600 University Boulevard, Evansville, IN 47712, USA
Reagan Lawrence: Bronstein Center for Healthy Aging and Wellness, Kinney College of Nursing and Health Professions, University of Southern Indiana, 8600 University Boulevard, Evansville, IN 47712, USA
Della Evans: Deaconess Geriatric Fellowship Program, Deaconess Hospital, Inc., 600 Mary St, Evansville, IN 47747, USA

IJERPH, 2025, vol. 22, issue 4, 1-14

Abstract: Patient, provider, and community barriers challenge dementia diagnosis and management in primary care. Interventions emphasizing EHR-based workflows with minimal provider training are insufficient to address these challenges. To improve early detection, dementia care, and the global health of caregivers and patients living with dementia, interventions must take a more comprehensive approach, addressing provider education and helping families be aware of the community supports available. Methods: Through a retrospective evaluation utilizing secondary data sources, researchers examine the results of a dementia care intervention that involved a clinical workflow, semiannual dementia training, and the integration of a care coordinator from an Area Agency on Aging (AAA) into the primary care team. Results: Seventeen caregivers received education and referrals to support during the intervention year and again in the final year. This represented 5.3% of the 322 patients diagnosed with dementia and with medical visits at the three clinics in 2023 During the last two grant years, there also was a large increase in provider referrals; thus, dementia care referrals decreased in proportion to patient referrals overall. Conclusions: Utilizing AAA care coordinators is a promising model for addressing health-related social needs in primary care. Yet, findings point to the complexities that remain in managing dementia in this setting.

Keywords: dementia; early detection and diagnosis; comprehensive assessment; community-based support and services; caregiver support; provider education (search for similar items in EconPapers)
JEL-codes: I I1 I3 Q Q5 (search for similar items in EconPapers)
Date: 2025
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