Nome health system uses Indian Health Service grant to expand in‑home dementia care

Norton Sound Health Corporation in Nome, Alaska, said it is expanding a dementia‑focused in‑home care program supported by an Indian Health Service FY2023 dementia grant, Christine Schultz, director of patient support services, told a U.S. Department of Health and Human Services panel.

The program is aimed at people age 60 and older across a service area the presenter described as roughly the size of West Virginia and covering 15–16 villages and Nome, a community of about 4,000 that is reachable only by air. Norton Sound’s initiative includes increased community outreach, standardized screening, multidisciplinary case review and funding for respite and personal care attendants.

Schultz said the grant is intended to “honor our elders by making sure that they get what they need at home and can stay in their community of choice.” The program organizes five “drivers” of care: awareness and recognition, accurate diagnosis, coordinated services, follow‑up continuity and caregiver support. It has used outreach such as village health fairs, quarterly newsletters delivered to every household and radio programs in local languages.

Norton Sound provides primary care and hospital services for the region, Schultz said. The system operates an 18‑bed acute hospital (with a swing‑bed program), an 18‑bed long‑term care center currently being expanded to 30 beds, and clinic sites in every village. Services cited during the presentation include about 17,000 clinic visits a year, roughly 1,000 hospital admissions annually, about 13,000 patient lodging bed nights for travel to care and roughly 7,000 medical social work encounters annually.

To improve diagnosis and continuity, Norton Sound standardized screening tools (Schultz said the SLUMS instrument is used) and is integrating dementia documentation in a systemwide electronic health record so village clinic notes, Nome clinics and tertiary care are linked. The program convenes a multidisciplinary team that meets monthly and evaluates at least four patients per month, Schultz said.

Schultz described direct service metrics: personal care attendants made more than 2,500 home visits in the last year and in‑home care coordinators recorded about 700 patient encounters. Through the Indian Health Service grant the program delivered about 175 hours of respite in its first year; other funding sources supplied an additional roughly 1,500 respite hours, Schultz said.

The presentation identified operational challenges. Telehealth and home‑based virtual visits are limited by high connectivity costs and inconsistent home internet in remote villages; clinics have better connectivity than individual homes. Workforce shortages and unfilled personal care positions limit in‑home capacity, and local construction and contractor shortages make environmental home modifications difficult. Schultz noted that five villages lack running water and sewer, which creates heavy chore needs (hauling water, removing snow, managing waste) that are essential to enabling elders to remain in place.

Schultz also cited gaps in neuropsychological testing capacity: Norton Sound lacks an on‑site psychologist for comprehensive neuropsych testing but is hiring one to begin in the coming quarter. The program uses hospital admissions under the swing‑bed program when necessary to perform evaluations when home visits are not feasible.

Schultz closed by underscoring cultural and community strengths that support elders: tribal governance with direct community representation, subsistence food sharing, multigenerational housing and community vigilance for wandering elders. She acknowledged program partners, her organization’s consumer‑directed board and Indian Health Service for the grant opportunity.

Looking ahead, Norton Sound’s stated goals include making the dementia program sustainable beyond grant funding, increasing in‑house cognitive testing capacity, improving home‑based service delivery and ensuring standardized dementia care across the continuum so “the elder to have the longest amount of time at home as possible,” in Schultz’s words.