BRI Care Consultation™

Comprehensive dementia care is a coordinated, person-centered approach that addresses not only memory and thinking changes, but also the person’s physical health, emotional well-being, daily functioning, safety and support for caregivers. It typically evolves as dementia progresses.

There are many aspects of comprehensive dementia care that are traditionally not provided through a medical facility and do not require medical personnel to initiate. These include:

Social and community services: Adult day programs, home health services, meals and transportation assistance, memory care programs

Individualized care planning: A personalized care plan based on the person’s needs, preferences, values, and goals

Management of behavioral and psychological symptoms: Strategies for agitation, anxiety, depression, hallucinations, wandering, or sleep problems

Functional support: Assistance needed withbathing, dressing, eating, as well as medication and financial management

Safety planning: Home safety evaluation, fall prevention, wandering prevention strategies

Caregiver support: Education about dementia and disease progression, training in caregiving techniques, emotional support and counseling, respite care options, support groups 

Care coordination: Communication among primary care providers, specialists, therapists, pharmacists, social workers, and community services, assistance navigating healthcare and long-term care systems

When implemented well, comprehensive dementia care can improve quality of life for the person with dementia, reduce behavioral symptoms and caregiver stress, help people remain safely at home longer when appropriate. Additionally, it can reduce avoidable emergency department visits and hospitalizations, and improve coordination across healthcare providers.

For these reasons, many healthcare systems and insurers now offer structured comprehensive dementia care programs that include ongoing care coordination, caregiver education, regular follow-up, and access to community resources, rather than focusing only on office visits or medication management.

Many organizations utilize what are called Care Navigation or Care Coordination programs. These are comprehensive caregiver support programs that provide guidance, education, skills training and community resources to family members caring for a loved one. Some also incorporate strategies to encourage physical, emotional and social self-care for the caregiver, too.

Evidence-based care navigation program BRI Care Consultation, for example, maintains a framework that addresses 35 areas of potential need, with 11 of them directed toward caregiver well-being.   

Care Navigation programs provide the structure and framework to deliver comprehensive dementia care apart from medical considerations. Evidence-based BRI Care Consultation, for example, is a proven program in which highly-trained Care Navigators work with family caregivers to address 35 potential physical, social and emotional issues, develop an individualized care plan, and guide the care partners toward lasting solutions.

Families can find programs and resources offered through a variety of organizations. They can begin by reaching out to their state’s Department on Aging, and their local Area Agency on Aging. Those resources should be able to either provide programming or direct them to service providers. They can also contact their local chapter of the Alzheimer’s Association for guidance.

Family caregivers can also visit Best Programs for Caregiving (bpc.caregiver.org), a free national directory of proven dementia support programs. By searching on their zip code they can find programs that are offered locally, or nationally available online or by telephone. 

Comprehensive assessment: Evaluation of memory, thinking, language, and problem-solving, review of medical history and medications, a physical and neurological examination and assessment of mood, behavior, sleep, nutrition, and mobility.  

Medical management: Diagnosis and staging of dementia, treatment of reversible causes of cognitive decline when possible, management of chronic conditions such as diabetes, heart disease, or hypertension, appropriate use and monitoring of dementia medications, if indicated.

There are a number of medications and treatments available today that can slow the progress of symptoms when caught early, as well as clinical trials for new treatments that may be shown to have positive results.

Additionally, evidence-based programs like SHARE for Dementia are available for individuals with early- to moderate-stage dementia and their primary caregivers to help them plan for the future. This provides the person with dementia a voice in their future care, and the caregiver a realistic, practical care plan to reduce future stress and undue burden.   

The personalized care plan is based on the person’s needs, preferences, values, and goals. Advance care and planning are vital to truly understanding the wishes of the person with dementia. Even without pre-planning, the care plan takes into account current needs of the care partners and structures needed tasks and activities to be accomplished into a comprehensive planning document.

Care Navigators provide strategies for managing agitation, anxiety, depression, hallucinations, wandering, and sleep problems. Emphasis is typically placed on non-drug approaches before medications. Educating caregivers to recognize triggers and respond effectively is also an important technique.  

Care Navigators work with family caregivers to understand the challenges the person with dementia has performing the “activities of daily living,” such as bathing, dressing and eating.As needed, caregivers can participate in in-person or virtual training classes to improve their ability to help their loved one perform these tasks. There may be instances where occupational, physical or speech therapy may be beneficial to consider, as well.

In a comprehensive care navigation program, the Care Navigator is also responsible for promoting self-care for the family caregiver. Self-care can take many forms, including respite time to relax and recharge, stress-relieving techniques like yoga and mindfulness, managing physical health, and participating in support groups. 

Comprehensive dementia care evolves as a person’s symptoms and needs change. Early in the disease, care often focuses on confirming the diagnosis, identifying treatable contributors to cognitive changes, managing medications and other health conditions, maintaining independence, and establishing legal, financial, and advance-care plans.

As dementia progresses, the focus shifts toward supporting daily activities, preventing falls and other safety concerns, managing behavioral or psychological symptoms, addressing nutrition and sleep, and providing increasing support for caregivers. Care plans are regularly reassessed so that treatments and services remain appropriate.

In the later stages, care generally emphasizes comfort, dignity, symptom relief, prevention of complications, and assistance with basic needs such as eating, bathing, mobility, and communication. Families may also receive guidance about home care, skilled nursing or residential care, and hospice or palliative care when appropriate.

Programming should include an assessment of the ability to perform activities of daily living (bathing, dressing, eating), providing caregiver skills training, or assistance in identifying other resources to help. Functional support also includes help with managing medications, finances, shopping, and transportation.

An initial home safety evaluation is a good start in assessing needed changes in the living environment. Fall prevention techniques should be implemented, as well as an emergency preparedness plan. As the disease progresses, wandering prevention strategies often come into play.

When implemented well, comprehensive dementia care can improve quality of life for the person with dementia, reduce behavioral symptoms and caregiver stress, help people remain safely at home longer when appropriate. Additionally, it can reduce avoidable emergency department visits and hospitalizations and improve coordination across healthcare providers.

For these reasons, many healthcare systems and insurers now offer structured comprehensive dementia care programs that include ongoing care coordination, caregiver education, regular follow-up, and access to community resources, rather than focusing only on office visits or medication management.

Many organizations utilize their Title III funding to support their caregiver initiatives. Grants provided through ACL and other foundations often encourage the inclusion of an evidence-based program within proposals, and many states are now beginning to implement state-wide dementia care programs and provide funding to counties or regions to execute the initiatives. 

The GUIDE Model from the Centers for Medicare and Medicaid is an example of a comprehensive dementia care program. GUIDE includes the medical components of assessment, treatment and medication management, as well as the full complement of community-based services included in Care Navigation. GUIDE was developed to serve as a model for comprehensive dementia care delivered by both health systems and community-based organizations to benefit families facing dementia.