# Presentation: 204687

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

## Lisa Dinwiddie MS, RNCornerstone 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

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

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

## 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.

## 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.

## 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

**Notes:**
With ADDGS grant funds

## University of Nevada School of Medicine Compressed Video Sites

**ELKO**

**LAS VEGAS**

**RENO**

## 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

**Notes:**
Steady growth in patients and variety of diagnosis and problems

##  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?

**Notes:**
Explain the HRSA grant

## 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

**Notes:**
It is easy to be enthusiastic when you realize the professionals with whom you are working are the best – we were providing a unique and excellent integrated practice model: medical, nursing, behavioral.

## 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

## 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

## 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.

## 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

**Notes:**
Many physicians still resist. After 2 years just got my first physician referral from outlying community after waiting to hear from specialist in Idaho over 4 months. 

## 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

## 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.

## 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.

## Contact Information

- Lisa Dinwiddie MS, RN  775-738-8411/ 775-934-3468, fax: 775-738-7837 _[cstonehm@frontiernet.net](mailto:cstonehm@frontiernet.net)_  P.O. Box 279 Elko, NV 89803. Program Coordinator
- Sylvia Elexpuru BSN,RN 775-934-5704 Grant administration, _[esap1@frontiernet.net](mailto: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](mailto:dfredericks@medicine.nevada.edu)_