The Logan Health Dementia Support Program is a home-based care coordination program designed to support people living with Alzheimer’s disease and other dementias who wish to remain in their homes, while also supporting the caregivers who help them every day.
This program follows evidence-based principles reflected in the CMS Guiding an Improved Dementia Experience (GUIDE) Model, which focuses on coordinated, person-centered care that addresses both medical and social needs. Research shows that people living with dementia often experience better outcomes when they can safely remain at home with appropriate support and care coordination.
The Logan Health Dementia Support Program provides structured support over a six-month enrollment period, offering regular contact and individualized care planning to help patients and families navigate the challenges of dementia.
Comprehensive Initial Assessment
The program begins with an initial visit conducted by a Logan Health Advanced Practice Provider (APP). This comprehensive assessment is designed to understand the full scope of the patient’s medical, cognitive, and social needs.
During this visit, the care team evaluates:
- Medical history and current health concerns
- Cognitive status and dementia-related symptoms
- Medication management and potential risks
- Functional abilities, including Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs)
- Caregiver capacity and support needs
- Home safety and environmental risks
- Current services and community resources
- Long-term planning considerations
This assessment helps the team develop a personalized care plan that reflects the goals, preferences, and needs of both the patient and their caregiver.
Ongoing Dementia Navigation and Support
Following the initial assessment, patients and caregivers meet monthly for six months with a Registered Nurse Dementia Navigator through home visits, clinic appointments, or telehealth.
The Dementia Navigator serves as a consistent guide and partner for families, helping them navigate the day-to-day challenges of dementia care. During these visits, the navigator works with families to:
- Follow up on care plan action items
- Provide dementia education and practical caregiving strategies
- Address behavioral symptoms and communication challenges
- Review medication and health changes
- Improve home safety and reduce fall or wandering risks
- Connect families with community resources and support services
- Provide caregiver coaching, problem-solving, and emotional support
The program also helps families address important planning topics such as:
- Legal and financial planning
- Future care planning and decision-making
- Support groups and caregiver resources
- Community services that help sustain care at home
Care Coordination and Resource Connection
Throughout the program, the team coordinates closely with the patient’s primary care provider and other healthcare professionals. The goal is to ensure that patients receive the right care at the right time, while avoiding unnecessary emergency visits, hospitalizations, or institutional placement when possible.
Interventions may include:
- Care coordination across healthcare providers
- Referrals to community resources and supportive services
- Environmental safety recommendations
- Dementia care education
- Behavioral management strategies
- Informal counseling and caregiver support
Program Completion and Ongoing Planning
At the end of the six-month program, patients and caregivers meet again with the APP for a final assessment. During this visit, the care team reviews progress, updates care recommendations, and helps families develop a clear plan for ongoing support.
The goal is to ensure that individuals living with dementia and their caregivers have the knowledge, resources, and support they need to continue living safely at home with the best possible quality of life.
Improving Quality of Life and Reducing Health Care Costs
By providing proactive care coordination, education, and caregiver support, the Logan Health Dementia Support Program aims to:
- Improve quality of life for patients and caregivers
- Reduce caregiver stress and burnout
- Prevent avoidable hospital visits and crises
- Delay or prevent nursing home placement when it is not the patient’s preference
Logan Health Dementia Support Program
245 Windward Way, Suite 101
Kalispell, MT 59901
If you are interested in a referral to this program, please contact your primary care provider.