Jane Dailey is Vice President of Clinical Operations, East Region and Southeast Region, in the Hospital Division of Kindred Healthcare. She provided an update on the Cognitive Care pilot in Dallas, starting first by recognizing what she called “an amazing group of people” in the Dallas-Fort Worth integrated care market. The folks who have been working on the pilot “wanted to continue the impact from the 2013 symposium,” Dailey notes. One year later, she says, “we have identified processes across the continuum that will allow us to promptly screen and evaluate patients with cognitive issues.”

The deliverables, she says, are fairly simple, and include a plan of care based on cognition, and delivery of Cognitive Capable care as observed in patients by the Care Transitions Team. She displayed the Cognitive Capable Care Process flowchart, which starts with admission, when patients are screened for cognitive issues. When issues are detected, the patient automatically receives further evaluation. There is also a change to the patient and family education process to address the cognitive issues.

The team began tracking patients in November of 2013 and conducted education and training for cognition in all Phase I sites in October 2014. The plan is to roll out the pilot to the entire Dallas-Fort Worth metroplex by March of next year. The ongoing success of the project, Dailey says, is possible because the group has a common goal regardless of where they are located, and there are no silos to prevent sharing and learning among the team.