Bob Feigenbaum

Dementia affects about 4 million to 5 million people in the United States. It affects about one percent of people aged 60 to 64 years and as many as 30 percent to 50 percent of those aged more than 85 years. Dementia is a cause of significant morbidity and mortality and is a leading cause of institutionalization. It places a substantial burden on patients and their caregivers. 

Patients with dementia present a significant diagnostic and treatment challenge to primary care physicians. The leading types of irreversible dementia: 

This month's Clinical Centers of Excellence series features facilities offering comprehensive diagnostic modalities and state-of-the-art treatment modalities including investigational protocols for dementia. The centers also use behavioral interventions and support care. 

The dementia centers were chosen based on a survey of neurologists. Each center was asked to provide patient statistics, research protocol information, and other pertinent dementia management features. We do not rank the centers relative to each other but highlight what makes each one unique. We could not profile them all but have included a list of the other Clinical Centers of Excellence identified by our survey (see the accompanying list). 

 editors also have gathered management and referral tips from the experts associated with the featured centers. These tips may be useful when managing patients with seizure disorders in the primary care setting. 

Articles

This month's Clinical Centers of Excellence series features facilities offering comprehensive diagnostic modalities and treatments including investigational protocols for dementia.

Clinical Centers of Excellence:
Diagnosis, treatment of dementia

Medicare provides coverage for 10 hours of diabetes education during a 12-month period. Once that first hour appointment is made and Medicare is billed, the clock is ticking and the patient must complete the other nine hours within a year of that first appointment. After that, a Medicare beneficiary is covered for only two additional hours of diabetes education per year.  

"This is not enough," says certified diabetes educator Marcia D. Draheim, RN, president of Draheim Dimensional Presentations in Cedar Rapids, Iowa, and president of the American Association of Diabetes Educators. "The AADE is trying to work with Medicare . . . to get this changed so we adopt a chronic care model. We must invest more in prevention rather than wait until the complications occur and become worse." 

But there are signs that things may be improving. "Many health insurers are now starting to provide healthy living education to patients through home mailings and phone calls, to impress upon them the importance of taking care of their diabetes," says Scot G. McAfee, MD, a psychiatrist at St. Vincent's Hospital in New York City, with expertise in the psychological aspects of chronic medical disorders. 

"Physicians are going to be pleasantly surprised as reimbursement starts to improve for this," says Stephen W. Ponder, MD, FAAP, CDE, medical director of the South Texas Children's Diabetes and Endocrine Center at Driscoll Children's Hospital in Corpus Christi. Ponder developed the Diabetes HouseCall Concierge Program, which uses web-based and electronic technologies to educate cardiometabolic and diabetes patients. 

Ponder reports that the program is making "dramatic breakthroughs" in acquiring third-party reimbursement support, including Blue Cross/Blue Shield, and that it has received growing support from Medicaid and several nationwide private insurers. He believes this increasing reimbursement will accelerate the rise of these programs. 

Insurers are signing on to support new chronic care patient education delivery systems that incorporate web-based and electronic technologies.

Getting reimbursed for patient education

There are positive steps you can take to help your nonadherent patients adhere to treatment and make lifestyle changes. 

"Nonadherence for one patient is not the same as nonadherence for another," says Scot G. McAfee, MD, a psychiatrist specializing in the psychological aspects of chronic medical disorders. 

One patient with cardiometabolic disorders may not take his oral medications, and that's typically what people think of when they say "nonadherence," says McAfee. It may be a refusal to take medication because the patient may actually not believe that he needs the medication, or he may fear adverse side effects. 

McAfee recommends primary care physicians consider a referral to a mental health provider for patients who remain nonadherent to therapy or lifestyle changes even after extensive patient education efforts. He cautions, however, that such a referral could result in considerable resistance. 

"The patient may feel 'Now I have two things wrong with me-I've got diabetes and they think I'm crazy,'" says McAfee. 

It's very difficult to come up with referral guidelines that apply to all patients, says McAfee. He adds that if the primary care physician believes the patient is depressed and that the pessimism that is generated by the depressive illness is affecting the patient's ability to feel optimistic about his care or his ability to manage the disorder, a referral is indicated. Then the psychiatrist or mental health provider can treat the patient's depression and, ideally, help the patient become more optimistic and motivated to take his medications for hypertension, blood lipids, and diabetes, and adopt the appropriate lifestyle changes. 

"Patients who are having complicated medical issues do not need to be burdened by a psychiatric illness at the same time," says McAfee. 

Consider a referral to a mental health provider for patients who remain nonadherent to therapy or lifestyle changes even after extensive patient education efforts.

When to refer a nonadherent patient to a mental health specialist

 spoke with a number of physicians and other healthcare providers about the many ways they educate their patients with cardiometabolic disorders. Though each physician has his or her own preferred modalities, they agree that successful patient education begins with you, the primary care physician. Following are their insights into ways you can use education to maximize the health of your patients. 

During a recent "heart-to-heart" visit, he employed this approach to encourage an obese patient to improve his diet. Rather than choosing high-fat meals at the fast food drive-through window, the man was encouraged by Hood's message to go hunting in the woods for the meat that he craved. The man followed Hood's recommendation-and lost nearly 40 pounds in three weeks. 

"This shows that the individualized message is the most effective," says Hood. 

David Spees, MD, a family physician with the 400-physician Sharp Rees-Stealy Medical Group in San Diego, California, also finds that the personal touch motivates patients to better care for themselves. That's why he provides handwritten lipid and blood pressure goal statements, each of which lists the patient's levels at the current office visit, what it was at the last visit, and what the goal is. If a patient's levels go in the wrong direction, Spees determines what went wrong, then works with the patient to get him back on track.  

"I always positively reinforce my patients when they have a success, even if they're just 

 about moving along the decision curve to take action," says Spees. 

Your own positive approach to motivating patients can empower them to make better choices, says Stephen W. Ponder, MD, FAAP, CDE, medical director of the South Texas Children's Diabetes and Endocrine Center at Driscoll Children's Hospital in Corpus Christi. Emphasizing positive reinforcement is vital to transforming long-term behaviors, he says, though many physicians overlook their tendency to provide subconscious negative reinforcement. 

Motivation is a key tactic used by Iresha Goonesinghe, MD, FACP, FACC, an internist and cardiologist in Ridgecrest, California. Three-fourths of Goonesinghe's patients have cardiometabolic disorders, she says, and she sees 250 of them each month.  

Goonesinghe spends considerable time learning about her patients' motivations and trying to resolve their social and emotional stressors. She then works with them in setting small, achievable lifestyle goals at each visit. 

"I try to change, for example, what a patient might eat at one meal, rather than the whole diet, so the patient has a sense of achievement," she says. When that patient returns with news of her modest success, Goonesinghe builds upon it with positive reinforcement and encourages the patient to embrace a new increment of improvement. 

Ken Gross, MD, an endocrinologist with the Polyclinic in Seattle, emphasizes health and not necessarily weight, and encourages patients to exercise and cut down on their calories and unhealthy foods.  

The art of medicine can be as pivotal as the science of medicine when it comes to managing the treatment regimens of patients with cardiometabolic disorders.

Author | Bob Feigenbaum

Articles

Clinical Centers of Excellence: Diagnosis, treatment of dementia

Getting reimbursed for patient education

When to refer a nonadherent patient to a mental health specialist

Improve your management of cardiometabolic disorders