Two different primary care approaches for caring for people with dementia and their families

Author(s): Palumbo, M.V. and Rambur, B.

Published In: Journal for Nurse Practitioners, 16 (10): 754-761.

Study Aim/Purpose:  The authors compare the experience and perspectives of primary care providers using the widely disseminated New Zealand Framework for Dementia Care to that of primary care providers in Vermont working in a statewide, value-based all-payer accountable-care system.

Summary of Methods: The authors conducted semi-structured interviews with five general practitioners (GPs) from two regions of New Zealand and six nurse practitioners (NPs) working in 2 adjacent Vermont counties. The interviews lasted 20 to 60 minutes and were recorded and transcribed. Two researchers coded the text using qualitative analysis software and a larger team identified themes and patterns in the coded text. Review by peers and debriefing among the team were also utilized to support confirmability and credibility of the findings.

Summary of Results:  

New Zealand providers: Primary care providers from New Zealand described the national Framework for Dementia Care as having the following strengths:  1) a well-financed and progressive pathway of care grounded in primary care, including early diagnosis and assessment of caregiver support, 2) available supports for both diagnosis and management of dementia, 3) timely backup by specialty providers, and 4) comprehensive training on topics including awareness of cultural differences in families’ views on obtaining help. While physicians were the primary care providers in this model, the GPs noted that primary care nurses play an important role in the New Zealand model, providing ongoing visits with the patients and their families. Providers also highlighted the fact that the guidelines for the Framework place the family at the center of care within a supportive, integrated primary care-led team. They also stressed the value of having a strong interdisciplinary team communicating closely with the families as a way to overcome barriers families face to using respite and support services.

Vermont providers: Interviews with NPs in Vermont revealed three key themes that differ from the New Zealand model. First, their comments revealed that the approach used in the Vermont model is reactive rather than early and proactive, often leading to a difficult and painful diagnosis for the individual, family, and providers. In fact, some providers clearly expressed hesitancy to provide dementia screening in part because of the limited access to specialty clinicians who are trained to make the diagnosis. They explained that access to these specialists is limited due to several factors, including wait times for appointments, distances to the center, and family ambivalence. To improve the quality of care for people with dementia and their families, the NPs recognized the need for interprofessional care teams, care coordination, and referrals to respite care.

Study Limitations (as cited by authors):   The authors noted the limited scope of this study, having interviewed only six providers from two areas of New Zealand and five providers from one state in the U.S. They also explained that, while their research identified practices from New Zealand that are potentially adoptable in the U.S., no systematic evaluations of the effectiveness of the New Zealand Framework for Dementia Care have been conducted.

Authors’ Discussion/Conclusions:  The authors suggest that NPs in the U.S. should be able to lead interprofessional teams for dementia patients, thus improving access to and quality of care. To enable this change, the authors recommend the following supports be provided in the U.S.: a) enhanced provider education on dementia diagnosis and management, including cultural factors affecting families’ use of and access to services, b) tools and supports to help providers be proactive through routine screening and diagnosis of dementia, for example, by assuring follow-up when a patient fails a cognitive screen during a Medicare Annual Wellness Visit or is identified as having memory loss, and c) telehealth and virtual care tools to improve communication with families and enhanced care coordination.