Advanced Practice Providers in Dementia Care: Optimizing All Providers on the Care Team

With more than 355,000 nurse practitioners and 168,000 physician assistants in the United States, advanced practice providers (APP) comprise a large component of the health care provider workforce.^1,2

Diagnosis and treatment are core components of the education, training, and scope of practice of APP, who are licensed independent practitioners. The extent to which these care providers engage in specific activities is influenced by state legislation and practice acts as well as local practice policies and procedures. In outpatient specialist care, such as cognitive neurology, APP are engaged at every step in the care continuum, from diagnostic evaluation to symptom management, referral to research, and advance care planning. In published models of health system–based comprehensive dementia care, APP are the predominant clinician in patient encounters.²

Nearly 7 million Americans have dementia, and this number is expected to double by 2050. The majority of people with dementia (PWD) have symptomatic Alzheimer disease.³ There are well-documented problems in accessing a timely and accurate diagnosis of dementia as well as other issues related to diagnosis disclosure. Management of PWD includes disease modification when possible, symptom management, supportive care for PWD and their caregivers, and advance care planning. The dementia care provider workforce has not kept up with the increase in dementia cases, and there is a current and projected shortage of geriatricians, geriatric psychiatrists, and cognitive neurologists. Primary care providers who fill gaps not met by specialists may not be comfortable in their abilities to diagnose or manage dementia.⁴

The progressive and all-encompassing nature of the neurodegenerative diseases that cause dementia, the high and rising prevalence of illness, and the ripple effects of dementia on families and communities require a massive health care and community-based workforce. The traditional means of practicing medicine for dementia treatment do not suffice. New models of care and alternative payment models are emerging. It is time to maximize the contribution of the full provider workforce from diagnosis to end of life.

Diagnostic Evaluation

The role of the APP in diagnosis ideally is part of a collaborative process. Clinical guidelines for the diagnostic evaluation of symptoms most likely attributable to dementia recommend obtaining a comprehensive and detailed history of present illness; relevant medical, social, and family history; and objective testing, typically ordered on a referral basis, such as neuropsychologic testing and structural imaging. The APP may initiate an informed consent and preference discussion with the patient (as well as the potential informant or support person) about the process ahead and evaluate patient preference for detailed evaluation, testing, and result-sharing. The APP may conduct the initial intake visit and order relevant first-tier testing. The synthesis of available information on symptom expression and progression, along with results of initial testing, may be sufficient for a reasonable diagnosis, which would be disclosed according to patient preference. In cases of unclear etiology or complicated disease trajectory, consultation with a neurologist or other dementia specialist would be beneficial to determine needs for advanced diagnostic testing (eg, genetic or biomarker) or to review gathered information as part of a clinical case conference with dementia specialists.

The diagnostic process may be structured as electronic consultations (eConsults) or office or telemedicine encounters. The decision on workflow is based on staffing, the structure of the practice or health system, and local resources. In the case of an eConsult process, the neurology APP may conduct record review of first-tier testing ordered by primary care, including standard measures of cognition, function, and neuropsychiatric symptoms; laboratory results; and structural imaging. The reviewed data are synthesized to determine level of complexity, and the APP may recommend additional testing and evaluation, such as repeat brain imaging, lumbar puncture, EEG, or [¹⁸F]Fluorodeoxyglucose or amyloid positron emission tomography. Education regarding further testing, why these tests are recommended, and how they are performed are within the scope of an APP.

In absence of an eConsult process, the APP may initiate the evaluation to obtain an in-depth history, discussion of any previous diagnoses, medication trials, family history, and brain injury. The APP also reviews medications, comorbidities, and psychosocial factors that may be contributory to cognitive symptoms and conducts a full neurologic examination. If additional testing, such as a lumbar puncture, is required or recommended, this also can be completed by the trained APP.

If clinical presentation is consistent with the suspected neurodegenerative disease and confounding factors are excluded, an APP can disclose the diagnosis. In the eConsult process, the APP would communicate guidance on differential diagnosis and treatment recommendations to primary care. Recommendations may include office or telemedicine encounters with the APP or neurologist.

Ongoing and Follow-Up Care

After a diagnostic evaluation and disclosure of etiology and stage of illness, the plan of care often involves ongoing management by the APP. Treatments including disease-modifying and symptomatic medications that may be prescribed or monitored, along with nonpharmacologic interventions, referrals, and caregiver support. The APP may conduct regular (ie, annual) cognitive assessment and care planning visits. Ongoing treatment plans—based on cognitive, behavioral, functional, and caregiver measures captured during this encounter—are geared toward the goal of optimizing function and quality of life. Management of dementia by APP should follow published quality measures closely and is included in the Merit-Based Incentive Payment System (Table 1).

Cognitive Symptoms

The APP may interpret results of cognitive (eg, neuropsychologic) testing, provide brief recommendations to create a supportive environment, and share available tools such as technology-driven options during a clinic encounter. Implications of these results, such as driving cessation or the need for continuous supervision, should be conveyed to PWD and their caregivers. The APP may refer the patient to more intensive interventions, such as a cognitive empowerment program focused on lifestyle factors for cognitive resilience or cognitive rehabilitation.

Prescribing, titrating, and monitoring symptomatic treatments of cognitive symptoms with medications affecting acetylcholine, glutamate, serotonin, dopamine, and norepinephrine levels are within the APP’s scope of practice. Likewise, the APP may deprescribe agents contributing to anticholinergic burden or those that cause central nervous system depression. Dementia is a dominant illness (ie, one that becomes the lens through which other treatments are considered); therefore, the decision to alter the treatment plan of other chronic conditions is a negotiation best performed in the shared decision-making model.

Behavioral and Psychologic Symptoms

Behavioral symptoms are a major source of patient and caregiver distress and the most common driver for institutional placement.⁵ Treatment of behavioral and psychologic symptoms of dementia includes both nonpharmacologic and pharmacologic symptom management. A dedicated article elsewhere in this issue covers nonpharmacologic approaches to adverse behaviors associated with dementia. The APP may conduct a thorough assessment through interview of caregivers or observers, as well as examination of the patient for potential underlying physiologic causes of behavioral symptoms. Once the specific behavioral and psychologic symptoms of dementia have been determined, the APP may obtain informed consent from the patient and caregiver before treatment initiation or adjustment. The APP can provide brief education or refer caregivers for psychoeducational programs such as Savvy Caregiver or Resources for Enhancing Alzheimer’s Caregiver Health (REACH).^6,7 If high-risk medications are prescribed, the APP is responsible for appropriate monitoring for adverse events. In certain cases, cognitive-behavioral therapy can be a valuable component of the individual’s care plan.

Structure, consistency, and routine often play an important role in reducing behavioral and psychologic symptoms of dementia, because decreasing triggering stimuli can help alleviate troubling behaviors. Activities outside the home increase socialization for PWD and allow respite for caregivers. In addition, these activities reduce agitation and depression, improving quality of life.⁸ Some programs also may help individuals with medication management, basic activities of daily living, gardening, and other sensory-stimulating activities.

Decline in Self-Care Abilities

Assessment of self-care ability, often described as functional assessment, may be conducted with caregiver input as well as patient evaluation. Level of function often defines staging of the dementia syndrome, which is a required element of the cognitive assessment and care planning encounter (Current Procedural Terminology [CPT] code 99483; see Table 2). This encounter consists of 2 elements: 1) a visit with the patient and family member or caregiver that includes documentation of the items listed in Table 2; and 2) formulation of a written care plan based on a synthesis of the assessment from this visit that Includes plans to address specific symptoms and functional limitations as well as referral to community services as needed. Disclosing the stage of illness to the patient and caregiver is within the scope of the APP and forms the basis for anticipatory guidance and advance care planning.

To optimize self-care and daily living abilities and support patients and families through decline, the APP may recommend education for caregivers, such as the Learning Skills Together program⁹ to manage hands-on support at home or Car Fit (www.car-fit.org) for modifications to promote driving safety. Referrals for driving evaluations or in-home care may be ordered independently. The APP can complete documentation and required forms for adult day programs and residential care facilities (eg, assisted living or personal care homes); however, a physician may be required to complete required forms for nursing home or skilled nursing facility placement, depending on the state’s practice act. Referrals to therapists for physical therapy and occupational therapy will require physician orders if therapy is a part of home health. The APP can order durable medical equipment, such as canes, walkers, wheelchairs, hospital beds, and patient lifts.

Advance Care Planning

Advance care planning ideally involves an ongoing and evolving conversation with patients and families based on the current context of dementia illness. These counseling sessions may begin with what to expect over the next 6 to 12 months, because dementia in Alzheimer disease and related disorders follows a well-known trajectory. The APP should elicit and document the patient’s and caregiver’s primary goals (eg, their goals of care).

Obtaining medicolegal documents, such as a health care proxy and living will, may be facilitated by the APP with relevant and feasible recommendations. Orders for life-sustaining treatments (eg, Physician Orders for Life-Sustaining Treatment or Medical Orders for Life-Sustaining Treatment) may be signed by the APP, depending on state practice acts. Orders for hospice care require collaboration with a physician. The APP may bill separately for advance care planning encounters (CPT codes 99497 and 99498).

Models of APP Care Delivery

Specialist as Consultant

Over the course of a dementia syndrome, quality care for patients and their care partners includes support for cognitive, behavioral, and functional symptoms to optimize quality of life. Recommended care can be achieved through the traditional specialist consultation model or through newer models of collaborative or comprehensive dementia care. APP play a central role in all of these models, along with physicians, social workers, allied health professionals, and community-based agencies.

In follow-up visits, the goal of the APP is to provide symptom management, information about community resources, and support for patients and their care partners throughout the trajectory of mild cognitive impairment or dementia. Follow-up care can facilitate access to appropriate research opportunities for those who are interested. The APP evaluates progression of cognitive symptoms and functional status, safety concerns, motor symptoms, sleep disturbances, and neuropsychiatric symptoms. The neurology APP can initiate medications, discuss nonpharmacologic interventions for cognitive resilience (ie, the Mediterranean or MIND [Mediterranean-DASH Intervention for Neurodegenerative Delay] diet, social and physical activity), and share relevant educational materials.

As part of the patient’s care team, the neurology APP communicates with primary care providers to manage medications that may negatively affect cognition, limit or reduce polypharmacy, manage vascular risk factors, and monitor medication adverse effects. When acute cognitive changes are observed, APP often collaborate with primary care to rule out metabolic or infectious etiology. An ongoing relationship with the primary care provider helps clarify goals of care and facilitate hospice and palliative care when appropriate. In addition, APP frequently refer to and collaborate with licensed clinical social workers specialized in cognitive impairment. Interdisciplinary care includes frequent referrals to physical, occupational, and speech therapy; sleep medicine; and geriatric psychiatry.

Comprehensive Dementia Care Models

The scope of disease management in dementia often is broader than that in health care management of chronic diseases, and includes social, legal, and financial issues in addition to cognitive and behavioral symptom management. Comprehensive dementia care models provide assessment and care planning, psychosocial interventions, and care coordination that focus on both persons with dementia and caregivers. They have demonstrated better care, improved outcomes, lower costs, improved workforce satisfaction, and increased health equity. These interventions share many common elements, including staffing with APP.

In health system–based comprehensive dementia care models, such as the UCLA Alzheimer’s and Dementia Care Program and the Emory Integrated Memory Care Clinic, patient and caregiver visits are conducted with APP who are dementia care specialists with physician support and consultation. At the Emory Integrated Memory Care Clinic, the APP also assumes the primary care provider role for enrolled patients.^10,11 In these models, the APP manages the dementia syndrome in the context of other chronic and acute conditions. Full-scope primary care includes appropriate screening and preventive care, including annual wellness visits, immunizations, and care coordination.

Comprehensive dementia care may result in avoidance of or reduction in incidents such as unnecessary emergency department visits or hospitalization. These models are preferable to the traditional fragmented primary care plus specialist model of care delivery.

APP On-Call

PWD may experience abrupt changes in their cognitive, behavioral, or functional symptoms. Individuals and families are best served with access to a provider for guidance on when to seek immediate medical attention for further evaluation. When these situations arise overnight or during holidays or weekends, the APP may participate in the after-hours call rotation to triage the situation quickly and provide families with real-time guidance on next steps.

Reimbursement for Care

For all interventions described in this article, the APP submits charges for the encounters as the rendering provider. Traditional Medicare reimburses 85% of the negotiated physician rate for APP. APP may bill incident to the physician; however, specific requirements must be met, including proximity of the physician and APP during the encounter. Typical services rendered and billed by the APP are similar to physician professional services, including eConsults, evaluation and management encounters, cognitive assessment and care planning visits, and advance care planning. In comprehensive dementia care models, the APP also may charge chronic, complex, and principal care management; annual wellness visits; and transitional care management.

Under the eConsult model, both the new patient visit and eConsult note are billed independently. Neurologists bill CPT 99999 for time spent reviewing imaging, cognitive testing, and functional questionnaire results, and completing eConsult notes. After the eConsult note is written and billed for, all subsequent visits are billed independently by the APP. The new patient and follow-up visits are billed based on time. Both new and established visits may be completed using telehealth and are billed under the aforementioned codes with the telehealth modifier, assuming there is parity within the state of practice.

Role of Neurologists

Whereas APP have an important role in the diagnosis of dementia and ongoing patient care, neurologists remain integral to these processes. Models for specialty consultation, collaborative care, and comprehensive dementia care all include physician members of the interprofessional team, although their specific responsibilities may differ. Medical care for complex conditions requires a highly functioning and interprofessional team in which all members are practicing at their highest level of education and training. Additional details about interprofessional team-based care may be found in another articles by Crooks and Geldmacher elsewhere in this issue. Dementia care may require a cognitive neurologist in case of atypical presentations, for management of complicated neuropsychiatric cases, or for management of disease-modifying therapies.

Given the current and pending demand for dementia care, all members of a highly educated and proficient health care workforce are critically needed. Underuse of APP or any member of the team will limit the quantity and quality of care for PWD.