Visiting Nurse Home Care & Hospice Makes Headway in Palliative Care program, Dementia Capable Community Initiative 

February 23, 2022

In 2020, the Mount Washington Valley received a multi-year grant from the Administration for Community Living Alzheimer’s Disease Program to help create a dementia-capable community. Visiting Nurse Home Care and Hospice of Carroll County recently reported progress in developing a new palliative care program as part of that initiative. Partnering with Memorial Hospital, Gibson Center for Senior Services, Northern Human Services and the MWV Adult Day Center, VNHCH’s program is focusing on two major areas – increasing early diagnosis and decreasing stigma. 

Grant Administrator and VNHCH board member Sue Ruka explained, “Early diagnosis is key. We are able to connect patients and families with support and programs. People can be fearful of palliative care. The disease is incurable, but you can have a healthy productive life. You can make a plan and have the best life you can. With an early diagnosis, you can get referrals and resources. The grant helps with all that.” 

VNHCH has hired Jennifer Grise, APRN, as Palliative Care Nurse Practitioner with the support of the grant. Grise explained the program’s four goals: 

● Increase screening both by the agency and by primary care providers. 

● Collaborate with primary care to increase cognitive screenings for 65 and older in Medicare Wellness Visits. The screenings are to flag any change in cognition or ability to care for themselves or interact with others. 

● Develop best available referrals for caregivers. 

● Raise community awareness around cognitive impairment and dementia. 

Grise explained what’s been accomplished in the first year of the program and what’s still to come during its 3-year term. “We’ve started screenings, care and support at home. We began a pilot program in October. We are starting with patients we already have seen as part of the agency’s palliative care or skilled care program. So far we’ve had 18 in-house referrals. I’ve seen these patients in the home and communicated with their primary care provider or their neurologist.” 

In January, they’ll start collaborating with primary care providers at Memorial Hospital. Grise added, “They are supportive and excited to increase screenings and have someone in the home to have eyes on their patients. It’s an extension of the kind of care you get with your regular provider. Primary Care Provider visits are short visits. We can expand upon what the PCP recommends, or provide services a PCP might not have time to get to in an office visit.”

VNHCH will eventually expand its palliative care efforts with other primary care practitioners in the region including Saco River Medical Group and Cranmore Health Partners. 

Grise outlined the process for those unfamiliar with palliative care. The Palliative Care Nurse Practitioner makes an initial visit to the patient home for a cognitive and functional assessment. She explained, “This would be challenging the client with screening tools to answer questions in many areas: memory, problem-solving, attention span, language, abstraction and general orientation. We also look at functional status, motor abilities, large and small motor skills, sensory changes, speech and swallowing. I assess whether the client can do activities of daily living, and how much assistance is necessary. I determine how the disorder has disrupted their household, their roles in the home, or their roles in the community. We discuss caregiver options and help define the families’ goals of care.” 

After the initial assessment, the Palliative Care Nurse Practitioner offers clients and family education about dementia. Grise explained, “One frequently misunderstood thing is that although there is no cure for the disease and that it inevitably progresses, there is care that can improve the quality of life for patients and their loved ones. People may not understand that dementia is a brain disease that affects all the connections in the brain and the nervous system.”

“I go into what to expect, both gradual and sudden: changes in vision, hearing, touch, proprioception and sensation. Voluntary movements can be affected – large muscle groups, and fine motor functions like using your hands to hold a utensil. Symptoms can include changes in coordination, balance, speech. It may impact understanding communications and expressions, and being able to find the words you want and use them to communicate.” 

The program comes at a time that Mount Washington Valley is facing a “silver tsunami.” New Hampshire is now tied for the second oldest population in the country and beginning to see the pressure on healthcare, services, and housing. Dementia is a prevalent disease. One in 9 people aged 65 and older has some form of dementia. 

Grise explained why palliative care for those with dementia is so critical: “Medical providers often can’t spend much time discussing dementia diagnoses, without many medical treatment options available and because of the short nature of most office visits. There may not be the time and opportunity to provide all the details of what to expect from this disease in an office visit. And, the client and family may need time to process the diagnosis of dementia before they are ready for more information Our program can expand on the screening and diagnosis done by the provider and explore what to expect and how to plan care. We can act as an extension of your health care provider in the home, and provide regular feedback to your doctor, practitioner, or specialist.” 

Grise seeks to guide and support caregivers with the best approaches at home. That includes hands-on care, or arranging for supplementary care either at home or in a day facility or nursing home. The VNHCH program often uses the Teepa Snow “Positive Approach to Care” concepts. Grise explained, “It’s a helpful model I’ve been using with these 18 families. It’s one tool I use when teaching best approaches to care.” Teepa Snow training was also supported by the ACL grant. 

As part of the palliative care service, they also review finances and find ways to get the help that’s needed. This may include referring to other agencies with qualified help, the MWV Adult Day Center, support groups, or even legal or financial help. 

Grise concluded, “We are part of the larger effort to help people stay in their homes and meet the goals of palliative care: decrease suffering and increase pleasure in the life that they have left. That’s the real focus. There is a stigma for any disorder that involves the brain. It’s similar to the stigma around mental illness. We need to remove that stigma. You need a multidisciplinary approach. You need community involvement, nursing, OT, pastoral care, financial assistance, social work, all of those things. There’s a lot of denial when a diagnosis is made. Family doesn’t want to ask for help until there is a crisis. We hope this program will help people make plans before there is a crisis.” For information about VNHCH’s palliative care program, visit them online at or call 603-356-7006.