This document describes Team290, which provides case management for patients with Alzheimer's and their caregivers. It discusses Team290's objectives of preventing caregiver overload and maintaining quality of life for patients and caregivers. The team is composed of coordinators, nurses, doctors, psychologists and support staff. The process begins with intake by a general practitioner or specialist, then an assessment by the case manager, doctor, and psychologist. A treatment plan is developed and implemented with ongoing case management, education and support for caregivers. Other services include medical clinics, discussion groups, and educational sessions. Strengths of Team290 include coordination across organizations, a comprehensive set of skills, and integrated diagnosis, treatment and support.

1. Convegno Famiglia e Alzheimer
19 ottobre 2011, Biella
Team290
Contents
• What is team290
• How does it work?
Case Management by team290
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2. Convegno Famiglia e Alzheimer
19 ottobre 2011, Biella
Tasks and objectives Team290
• Diagnostics
– Early medical diagnosis (of dementia and related problems)
– Care diagnostics (???? Wat is hier de intentie)
• Guidance, treatment, and support by Case
Management
• Objectives:
– Prevent overload of carers (family, spouse, children etc.)
– Retain an optimal quality of life for both patient and carer
Composition Team290
• Team co-ordinator
• Case managers
– Nurse, specialised in community psychiatry (SPV)
– Nurse + Social Worker
• Physician
– Geriatrician and/or psychiatrist
• Psychologist
• Team support and administration
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3. Convegno Famiglia e Alzheimer
19 ottobre 2011, Biella
Intake by team290
• Registration by GP/specialist
– Medical status
– Blood tests, was the NHG-protocol applied?
– Assign case manager and physician
– Urgency indication
– Home visit within 2 weeks
• Or by
– Nursing home, CIZ, home care organisation, MJD,
family, friends etc.
Intake Team290 (cont’d)
• Intake by the case manager
– Anamnesis/hetero anamnesis
– Identify burden to carer
– Physical condition and medication
– Preliminary medical diagnosis
– Identify required care (care diagnosis)
– Way forward (medical examinations, treatment and support
plan etc)
• Intake by geriatrician
– Medical anamnesis
– Physical examination (to exclude physical causes)
– Psycho geriatrical examination
– Medication
– File review
– Likely medical diagnosis
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4. Convegno Famiglia e Alzheimer
19 ottobre 2011, Biella
Intake team290 (cont’d)
• Neuropsychological assessment by
psychologist
• Assessment of cognitive abilities
– Type and severity of the dementia
– Advice to carer
• How to manage behaviour
• What is still possible?
• Subsequent assessments
• Adjustments to living environment needed? (day care,
nursing home etc.)
• * Neuropsychologisch onderzoek
Intake Team290 (cont’d)
• Diagnosis review (multidisciplinary team)
– Agree on diagnosis
– Classification according to DSM IV
– Define treatment plan
– Progress/evaluation meetings schedule
• Feed back session
– Diagnosis and treatment plan explained to
patient/client and family/carer
• Medical report
– Written report to GP and/or specialist
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5. Convegno Famiglia e Alzheimer
19 ottobre 2011, Biella
Implementation team290
• Case manager (tasks and responsibilities)
– Implement treatment plan and control progress
– Manage care requirements
– Educate and advise carer
– Active support and guidance
– Mediation
– Medication administration control
– How to deal with behavioural changes
– Crisis management
Other Services team290
• Outpatient clinic for medication
– Physician
– Psychologists
• Discussion groups
– Patient/client
– Carers
• Consultation
– Nursery homes
– Clinical lessons/Case studies (??)
– Lectures to carers
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6. Convegno Famiglia e Alzheimer
19 ottobre 2011, Biella
Strengths Team290
• Co-ordination
– Hospitals, CIZ, nursing homes, day care
• Broad competence and skills spectrum
– Mental health care, nursing homes, home care
• Integrated approach: diagnostics, treatment,
guidance and support
• Easy access
• Widely appreciated and supported
Thank you for your attention
Any Questions?
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