Dementia Care Works

Integrating Holistic Nursing Practice into Dementia Care

Learn More About the Project

Features

Screening Tools

Contains evidence-based screening tools and assessments to be used in a healthcare encounter.

Care Plans

Includes decision support tools, nursing guidelines and brief care plans to be utilized with the patient and family or care partner.

EHR Intergration

Capability for integration within EHR systems.

Explore Our Demo

Caring for a person living with dementia can be complex and challenging yet rewarding when done well. Utilizing the Dementia Care Works (DCW) platform will help nurses navigate the complexities of dementia care by guiding them through screening, assessments and care planning. Results of these measures can then inform the primary care provider’s (or prescribing clinician) treatment plan and additionally will meet core requirements for G0505 Care Planning code.

The demo version of Dementia Care Works currently allows the user to go through the assessment stages of the first two domains, Cognitive Health & Function and Emotional, Behavioral & Spiritual Health for a potential person living with dementia and their care partner. It then provides a longitudinal report of the person’s health over time to help nurses better assess and address dementia concerns.

Please contact the research team to view a demo and learn more.

Explore Dementia Care Works

Domains in Dementia Care Works

DCW is conceptually based the 6-part model for comprehensive dementia care that was created by Dr. Soo Borson. The domains include:

Cognitive Health & Function

This domain addresses overall cognitive status and treatments. Cognition includes remembering, learning, thinking, making decisions, being aware of social cues, planning head and everyday activities needed to live independently. Changes may be acute or chronic, stable or progressive.

Emotional, Behavioral & Spiritual Health

This domain addresses mental health symptoms (e.g. loss of motivation, anxiety, depression, hallucinations, delusions) altered behavior (e.g. sleep, emotional reactivity, disinhibition, aggressive outbursts), and their treatment and management.

Physical Heath & Function

This domain addresses general medical conditions and treatments and their impact on physical functioning and resilience. Frailty, mobility and falls, nutritional status, and sensory impairments (hearing, vision) are assessed in this domain.

Care Partner Capacity & Needs

This domain addresses how family members, friends, and other supporters deal with the demands of care and other aspects of their everyday lives. It includes assessment of how they manage stress, care for themselves, learn what they need to know about being a care partner, and access needed support and services.

Health-Related Social Needs

This domain addresses life conditions that influence wellbeing, health, social connection, and access to supportive care and services. Unmet needs may threaten personal safety, or result in housing or food insecurity or inability to purchase medications or travel to medical appointments and other essential services.

Care Delivery Framework

This domain addresses the attributes of dementia-capable health care systems. These include early detection of dementia, identification of care partners in electronic medical records, protocols for individualizing clinical care pathways, organization and function of clinical teams, access to care navigation, linkage to community-based services, and optimal use of reimbursement to benefit patients and families.

Why Dementia Care Works was developed

In the U.S., there are over 6 million people living with dementia (PLWD), who are cared for by 16 million family and friend care partners (CP). Dementia is a progressive and debilitating disease, which requires specialized care, yet only 30,000 geriatricians practice in the U.S. Therefore, many PLWD and their CP lack access to formal dementia care utilizing evidence-based practices. Health systems are additionally struggling to meet the unique needs of this population. Registered nurses are well positioned to meet the complex needs of PLWD and their CP yet have not been formally integrated into health system practice to provide this care. Hence, we developed the DCW platform in order to engage an interdisciplinary approach to dementia care that utilizes nurses’ skill set.

How Dementia Care Works was developed

Dr. Tatiana Sadak is a nurse researcher, educator and healthcare provider who has dedicated her career to improving care for people living with dementia and their care partners. Through her clinical experience and direct practice work, she identified multiple gaps in dementia care that include restricted access to specialists, limitations in clinician bandwidth to provide comprehensive care and workforce shortages in the field of geriatrics. These challenges inspired Dr. Sadak to revolutionize dementia care by integrating nurses as leaders in the healthcare team. While this work begins with nursing education and curriculum development, Dr. Sadak and her team quickly identified that full inclusion of nurses would require a change in infrastructure that is supported by healthcare leadership.

In June 2021, Dr. Sadak partnered with her colleague, Emily Ishado and participated in the University of Washington Co-Motion Innovation Corps program, which is funded by the National Science Foundation. This program aims to help academicians to commercialize product ideas through completing customer discovery activities, a lean business plan, and market analysis. Results from this project indicated that nurses are valued in healthcare settings, however supporting this level of staffing in outpatient settings is challenging, as nurses do not directly bill for services. Therefore, Emily Ishado spearheaded the project development of Dementia Care Works, a platform that will guide nursing care in dementia, be compatible within their workflow and contain components that can be used to support billing under the G0505 Care Planning Code. This project proposal and business pitch was presented to Co-Motion and was awarded the Innovation Gap Fund. With this funding, two domains within the DCW have been created by a team at the Clinical Informatics Research Group (CIRG) at the University of Washington.

About Us

Dementia Care Works (DCW) was created by the team at the University of Washington (UW) – Dementia and Palliative Education Network (DPEN), which is led by Dr. Tatiana Sadak, Associate Professor and Interim Associate Dean of Academic Affairs at the UW School of Nursing. DPEN aims to transform dementia care by training nurses to work at the top of their scope of practice in this field. While true dementia care involves an interdisciplinary team, we are initially focusing on nurses because they comprise the largest segment of the healthcare workforce and are well-suited to meet the health and psychosocial needs of people living with dementia and their care partners. The DPEN team includes distinguished local and global dementia clinicians, educators and leaders who are collaborating to develop a comprehensive curriculum that utilizes an anti-racist and inclusive framework that will be applicable to all healthcare disciplines.