Alzheimer’s Disease in the Frontier: The Use of Telehealth for Dementia Care in Rural Nevada

1. Alzheimer’s Disease in the Frontier: The Use of Telehealth for Dementia Care in Rural Nevada

2. 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

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

4. Nevada’s 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 by>100%. 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 > 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.

5. 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 Nevada’s 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.

6. Program Overview • 1994 opened Las Vegas Alzheimer’s 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

7. University of Nevada School of Medicine Compressed Video Sites ELKO RENO LAS VEGAS

8. 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

10. Impetus for Telehealth Expansion Expand clinic services Telehealth patients commuting > 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 can’t we see patients in their own communities?

11. 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 Alzheimer’s 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

12. 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

13. 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

14. Education Classes Started in Nevada Year 2 expanded education services to caregivers and professionals in rural Oklahoma- HRSA grantee contact Partner with Alzheimer’s 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.

15. 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 it’s own personality

16. 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

17. 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.

18. 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.

19. Contact Information Lisa Dinwiddie MS, RN 775-738-8411/ 775-934-3468, fax: 775-738-7837 cstonehm@frontiernet.net P.O. Box 279 Elko, NV 89803. Program Coordinator Sylvia Elexpuru BSN,RN 775-934-5704 Grant administration, esap1@frontiernet.net Gerald Ackerman MS, Director University of Nevada AHEC, Elko NV. 775-738-32828 gackerman@medicine.nevada.edu Charles Bernick MD, Lou Ruvo Brain Institute Debra Fredericks PhD, RNC,APN, 775-322-2731, dfredericks@medicine.nevada.edu