PRO DEM: A Community-Based Approach to Care for Dementia
Hesse, Eberhard, Health Care Financing Review
Early in 1998 a number of physicians in Stuhr and Weyhe (a region south of the City of Bremen with 80,000 inhabitants) decided to work more closely together. They negotiated an integrated contract of care with a statutory health insurance (VdAK). PRO DEM was one element of this contract. The planned cooperative network of physicians and statutory health insurance has not yet been put into practice. Sponsorship from the pharmaceutical industry, however, made it possible for a group of health care providers to launch PRO DEM. The sponsorship funds (nearly 250,000 U.S. dollars), were used during the first 2 years to pay for (1) the hiring of nurse consultants and their salaries, (2) provider incentives, and (3) the scientific evaluation (Klingenberg et al., 2001).
Caring for the elderly, one of the main tasks of general practice, includes caring for people with dementia. At the beginning, however, it was uncertain about how to deal with this problem in the communities properly. In an attempt to cope with this challenge, PRO DEM was initiated. During several weekend training sessions with one of the neurologists, additional help was sought out throughout the region. At first, the project's main goal was to bring everyone who cared in any way for the elderly to a forum. The nurse consultants employed specifically for this project, were to assume tasks in the fields of consultation and coordination in addition to general practice and neurological care. The Institute for Applied Quality Enhancement and Research in the Health System (AQUA) was assigned to monitor and evaluate this project from its inception. The project has developed positively and is now continued as a registered association which collects membership fees, private and community sponsorship payments, and receives additional funds for social interventions from the Lower Saxony's regional government according to the German Social Code Book No.XI [section] 45.
Detection and Treatment Sequence
Either the physician who diagnosed the patient with dementia or the family caregivers approaches the PRO DEM Consulting Center and meets a nurse consultant. PRO DEM's two nurse consultants are highly trained experienced professionals. The family physician performs his examination of the patient (according to standard protocol) assisted by his nurse (who has received special training dealing with dementia patients) and one of the neurologists who has seen the patient by referral. The nurse consultant goes to the patient's home and conducts a comprehensive assessment of the patient's clinical status and needs. The nurse consultant prepares a written report for the family physician showing the findings.
Following this assessment the nurse consultant, in collaboration with the family caregivers, the patient, and the family physician, develop a temporary individualized care management plan which is later discussed and agreed on in the PRO DEM Multidisciplinary Case Conference (MCC). The MCC, the central decisionmaking institution within PRO DEM's case management process, consists of the neurologist, family physicians, speech therapists, ergotherapists, physiotherapists, and nurses.
In addition to an evidence-based medical treatment, PRO DEM offers non-medical treatment called social intervention. This non-medical treatment is a distinctive feature of PRO DEM. It comprises a sequence of treatment and social response modules developed specifically for PRO DEM (German Society of Geronto-Psychiatry and Psychotherapy):
"The main precondition for the successful treatment of a patient suffering from dementia is a diagnosis made as early as possible as well as an overall therapy plan which, depending on how serious the illness is, comprises drug treatment, social and psychotherapeutic measures as well as care by members of the patient's family. This plan should be agreed on by the patient, his family, the doctors as well as the therapists concerned, careers and social services, taking into account the extent of the patient's illness. …