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As part of the Maine demonstration project, Community Health and
Counseling Services developed five evaluation teams to serve four
isolated counties in rural, northeastern Maine. Each team was made up of
a Social Worker and a Registered Nurse. The teams provided the only
dementia evaluation service in these remote areas. The evaluation
includes two home visits by the team, consultation with a geriatric
physician, the development of an individualized care plan, and two
telephone follow-ups.

In their initial visit, the team administers a battery of assessment
measures and tests. Each team member spends separate time with the
caregiver and the elder. Following the visit, the team reports all the
information gathered to the geriatric physician consultant. This
information includes the team\'s observations of how the family is
living, what coping strategies they are using and any environmental
safety issues or dementia education needs the family may have. The
geriatric physician and the team confer by conference call to develop an
appropriate care plan.

The second in-home visit by the team is to explain and assist in
implementing the care plan with the family. The geriatric physician also
sends a copy of the care plan to the family\'s primary care physician
and may follow up with a call when warranted.

# Why the Team Approach Makes Sense in Maine

Most of Maine is rural and sparsely populated. Though it is a
geographically large state, there is only one Geriatric Diagnostic
center in the central part of the state. Thus, to obtain an assessment
and diagnosis, most of Maine\'s elderly population had to travel long
distances which often included overnight stays. Given the long winters
and extreme weather, such travel can be difficult even when feasible.
Many families were simply unwilling or unable to travel for this
service. The in-home evaluation team model takes into account the
geographic size of Maine. It is an effective way to overcome
transportation problems and to increase access to assessment and
diagnosis for rural families. In-home assessment also has the benefit of
respecting the rural cultural mores of family privacy and \"tending
out\" (taking care of one\'s own). The assessment process is tailored to
each family\'s needs, which places the family in control.

# How the Team Approach Was Established

Some Health staff at Community Health and Counseling Services identified
the need for dementia services in rural areas. Some of the needs the
staff discovered went beyond routine home health issues. The social work
coordinator and the geriatric physician put together a proposal to
address the need for dementia assessments. The Maine demonstration
project funded the proposal for serving rural families with dementia
needs.

The project began by building community awareness. Letters were sent to
all physicians in the four-county area to introduce the services.
Currently, almost 35% of referrals come from physicians. Physicians are
willing to refer their patients to the service because they have trust
in the Home Health Agency and the local team. The Home Health Agency is
well- known in the four service counties. Many of the local physicians
and team members have prior working relationships through community
hospitals and nursing homes. The limited care options in rural areas
also encourage physician referrals.

Referrals also come from other community agencies. The teams meet with
hospital discharge planners, other home health agencies, other
providers, and professionals in the communities. Brochures are widely
distributed and local media are used (radio programs, television news
shows, and local television programs).

# How the Maine Program Works

Attention was given to communicating with local primary care physicians.
The presence of the team\'s geriatric physician was helpful in reaching
physicians. This facilitated communication from doctor to a doctor, even
though the team was gathering the information. The geriatric
physician\'s approach was very important. He was cognizant of the fact
that he had not seen the patient. He had seen only the assessment
measures, reports, and test results. He approached the primary care
physicians as the \"experts\" about the family and patient because the
primary care physicians had seen the patients and often had been
treating the family for a long time. The team\'s geriatric physician
served as a consultant with specific expertise rather than as an expert
telling the primary care doctors how to treat their patients. He gave
his recommendations as suggestions and offered to assist the primary
care physicians. The teams benefit because the geriatric physician\'s
role was critical in gaining the trust of the local primary care
physicians.

# Barriers and Obstacles

Previous programs had been unable to communicate effectively with
physicians. Having a registered nurse as a component of the team helped
legitimize the medical issues when conveying assessment information to
primary physicians. Lack of other options for assessment also may have
contributed to a willingness to use or refer to the team.

There is a general lack of knowledge about dementia in rural areas among
both providers and families. The geriatric physician\'s role, in part,
is as an educational resource to primary physicians. He is the only
geriatric specialist outside of Bangor in the four-county service
region. Additionally, the assessment teams became local resources. Some
teams were asked to train staff of residential care facilities on
dementia issues and others gave talks to the general public.

# Expanding the Service Capacity

Service capacity has been increased at multiple levels through this
program. In the initial phase of the project, contracts were negotiated
with the staff of the only Geriatric Diagnostic Center in the entire
state of Maine to provide training to the social worker and nurse teams.
The home health agency now includes dementia training for all social
workers, nurses and aides. Local physicians have also become more aware
of dementia issues. Teams are recognized as local experts and asked to
provide dementia information locally. General community awareness and
knowledge has also increased.

# How the Project Benefits Maine

This model has been so successful in serving rural families in a
sensitive and culturally appropriate manner that the Maine demonstration
project is planning to replicate the model in other areas of their
state.

Teams bring service to families who would otherwise not be served. Teams
work within the existing support network of each family (families do not
need to change physicians, etc.). This is possible because the teams
visit the family at home and thus have a first-hand understanding of how
the family is coping with dementia issues.

This model has also increased the general awareness of the needs of
dementia families. Now there is a greater likelihood that families will
seek help sooner. Having local dementia teams has also decreased their
feelings of isolation. Family members now know someone who understands
their situation and can help link them to available resources.

# Project Costs 

The team assessment costs approximately \$600 per family to deliver.
This cost covers two visits by the team, physician consultation and two
follow-up calls by the team. Also included in this estimate are the
associated costs for telephone and travel. The social work coordinator,
who also oversees the program, provides some in-kind contributions. The
coordinator arranges for training and provides information and other
support to the teams. To reduce the per-client costs, the service has
recently been changed. Now, only one team member returns to make the
second in-home visit with the family.

# Keys to Success

1.  The project became a partner with respected organizations that are
    already integrated into the service community.

2.  Team staff are employed as home health nurses and social workers.
    This alleviates financial stress during the start-up time or slow
    times when staff can serve other clients.

3.  The teams include medical staff to talk with physicians.

4.  The teams travel to the families, instead of vice versa.

5.  In-home visits provide the teams useful insight into the family
    environment.

6.  Teams make practical, informed suggestions for behavior management.

# Contacts: 

Administration on Aging: (202) 401-4547

330 Independence Ave.

Washington, DC 20201

Romaine Turyn: (207) 624-5335

Maine Alzheimer\'s Project; Bureau of Elder and Adult Services

State House Station 11

Augusta, ME 04333

John Shaw: (207) 947-0366

Social Work Coordinator

Community; Health and Counseling Services

Bangor, Maine 04402-0425

##### Other Projects that Serve Rural Communities: {#other-projects-that-serve-rural-communities .unnumbered}

Dawn Harlock: (850) 414-2060

Florida Alzheimer\'s Demonstration in West Palm Beach; Office of
Volunteer and Community Services; Department of Elder Affairs

4040 Esplanade Way, Suite #260

Tallahassee, FL 32399-7000

Cliff Burt: (404) 657-5336

Georgia Alzheimer\'s Demonstration

HRSA Site Coordinator; Division of Aging Services

2 Peachtree St. NW Ste. 36.385

Atlanta, GA 30303

Lisa Brakebill: (410) 561-9099

Maryland Alzheimer\'s Demonstration; Alzheimer\'s Association

1850 York Road, Ste. D

Tomonium, MD 21093

Irene Kazieczko or Dale Adler:

\(517\) 335-0226

Michigan Alzheimer\'s Demonstration; Michigan Department of Health

Lewis Cass Building, 6th Floor

Lansing, MI 48913

Marian Sigmund: (919) 733-3983

North Carolina Alzheimer\'s Demonstration; NC Department of Human
Resources

693 Palmer Dr.

Raleigh, NC 27626-0531

Barbara Kelly: (803) 253-6177

South Carolina Alzheimer\'s Demonstration; SC Department of Health &
Human Services; Office on Aging

PO Box 8206

Columbia, SC 29202-8206

##### The Administration on Aging is the official Federal agency dedicated to policy development, planning and the delivery of supportive home and community‑based services to older persons and their caregivers through the national aging network of state and local agencies on aging, tribal organizations, service providers and volunteers. {#the-administration-on-aging-is-the-official-federal-agency-dedicated-to-policy-development-planning-and-the-delivery-of-supportive-home-and-communitybased-services-to-older-persons-and-their-caregivers-through-the-national-aging-network-of-state-and-local-agencies-on-aging-tribal-organizations-service-providers-and-volunteers. .unnumbered}