Integrated Memory Care Clinic: Design, Implementation, and Initial Results
Abstract
The Integrated Memory Care Clinic (IMCC) is a patient‐centered medical home as defined by the National Committee for Quality Assurance directed by advanced practice registered nurses (APRNs) caring for persons living with dementia (PLWD); physicians provide specialty consultation but do not direct care or care planning. The IMCC incorporates geriatric nursing, social work, and APRNs from neurology, gerontology, palliative care, and geriatric psychiatry. APRNs provide comprehensive, coordinated primary care for dementia, other chronic conditions, and minor acute illnesses. Partnering with PLWD and families and taking a palliative‐oriented, dementia‐informed medical home approach, the IMCC aims to reduce dementia burden. This study describes the first 12 months of IMCC's operation with 139 enrolled PLWD‐caregiver dyads. All patients have a diagnosis of dementia or mild cognitive impairment; most have Alzheimer's disease (53.2%). Patients have an average of 5.8 medical conditions and 6.9 prescriptions; 38.1% have an advanced directive, a medical power of attorney, or a living will. Mean age is 78.6, 63.3% are female, and 30.9% are African American. Mean Montreal Cognitive Assessment score is 12.6. Most require assistance in activities of daily living. Many display neuropsychiatric symptoms. The most prevalent comorbidities are hypertension, dyslipidemia, and depression. The rate of ambulatory‐sensitive hospitalizations declined from 6.7% in December 2015 to less than 1% in May 2016. Caregivers were highly satisfied. We observed nonsignificant improvements in neuropsychiatric symptom severity (p=.07), caregiver distress (p=.69), and caregiver competence (p=.18). IMCC is a novel care model for PLWD and their caregivers and may be a more sustainable model than traditional primary care for this growing vulnerable population. J Am Geriatr Soc 66:2401–2407, 2018 .
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Improved healthcare professional understanding of the patient's care needs facilitated condition management.
“This emphasised a need to organise care around dementia to support transitions, as improved HCP understanding of the patient’s care needs facilitated condition management (CMOC24) [44, 60, 76, 77, 98].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [98]
Integrated memory care combining condition reviews with symptom management showed promise in reducing readmissions and urgent care use, which were not affected by number of conditions.
“For example, integrated memory care combining condition reviews with symptom management showed promise in reducing readmissions and urgent care use, which were not affected by number of conditions [65, 98].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [98]
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“For example, integrated memory care combining condition reviews with symptom management showed promise in reducing readmissions and urgent care use, which were not affected by number of conditions [65, 98].”
Influential
- Authors
- Clevenger, C. K., Cellar, J., Kovaleva, M., Medders, L., & Hepburn, K.
- Affiliations
- Emory Healthcare (US)
- Emory University (US)
- Corresponding author
- Clevenger, Carolyn K.
- Venue
- Journal of the American Geriatrics Society
- Publisher
- Wiley
- Published
- 2018-08-23
- Volume
- 66
- Issue
- 12
- Pages
- 2401-2407
- ISSN
- 0002-8614 (ISSN-L)
- 1532-5415
- OpenAlex
- W2888752528
- Cited by
- 49
- References
- 36
- Citations by year
- 2026: 6 · 2025: 12 · 2024: 7 · 2023: 3 · 2022: 4 · 2021: 9 · 2020: 5 · 2019: 1 · 2018: 2
- FWCI
- 3.33
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of the American Geriatrics Society (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institute on Aging (2P50AG025688)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
- Keywords
- patient-centered medical home, dementia care, Alzheimer's disease, advanced practice nurses, caregiver dyads, palliative care, neuropsychiatric symptoms, caregiver satisfaction, mild cognitive impairment, geriatric primary care, care coordination
- MeSH terms
- Aged, Dementia, Female, Geriatric Psychiatry, Geriatrics, Hospitalization, Humans, Male, Palliative Care, Primary Health Care, United States, Comorbidity, Caregivers, Patient-Centered Care, Advanced Practice Nursing
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