Partner with Dr. Gaby
A collaborative resource for your patients & care partners
MINDKIND is designed to serve as an additional layer of support — working alongside your medical team while keeping diagnosis, treatment, medication management, and clinical decision-making entirely within your practice.
Bridging the gap
Addressing the gap between diagnosis and ongoing care
A dementia diagnosis often creates a significant need for support that extends beyond medical management. Families may need ongoing education, help understanding disease progression, assistance coordinating services, behavioral guidance, caregiver support, safety planning, and preparation for future care needs.
These needs can also result in repeated non-clinical calls, portal messages, missed follow-through, and fragmented care within already busy neurology practices.
MINDKIND is designed to serve as an additional layer of support working alongside the neurology team while keeping medical diagnosis, treatment, medication management, and clinical decision-making within the patient's medical team.
Four integrated pillars
Four integrated pillars of care
MINDKIND brings together four complementary areas of support:
Clinical Assessment
Cognitive, functional, psychosocial, and care-partner burden assessment when clinically appropriate.
Care Navigation
Coordination of services, resources, appointments, and transitions across the continuum of care.
Caregiver Support
Education, coaching, problem-solving, and ongoing assessment of caregiver capacity and burden.
Longitudinal Monitoring
Structured observation of cognitive, functional, psychosocial, and caregiver changes over time, with appropriate escalation to the medical team when concerns arise.
Together, these components provide a more comprehensive understanding of the patient–care partner dyad and allow support to evolve as needs change.
A tiered model of support
A tiered model of support
Based on the CMS Guide Model of Dementia Care — the level of navigation increases as the needs of the patient and caregiver evolve.
Early Stage · Lower Complexity
- Initial patient–care partner clinical and psychosocial needs assessment
- Cognitive and functional assessment when clinically appropriate
- Care partner burden assessment
- Dementia education and individualized care planning
- Monthly follow-up and resource navigation
- Care partner education and support
Moderate Stage · Increased Complexity
- Ongoing care coordination and resource navigation
- Cognitive, functional, and care partner reassessment when clinically appropriate
- Care partner coaching and support
- Behavioral guidance and problem-solving
- Twice-monthly follow-up
- Identification of emerging safety, functional, and care needs
- Communication with the referring medical team when clinically indicated
Advanced Stage · High Complexity
- High-touch, frequent care navigation
- Intensive care partner support
- Ongoing monitoring of functional and care partner needs
- Safety and crisis escalation
- Assistance with transitions to higher levels of care
- Memory care and placement planning
- Hospice and end-of-life resource navigation
- Frequent communication and monitoring with the care partner and appropriate members of the care team
Patients can move between tiers as their needs evolve.
Clinical assessment
Clinical Assessment & Longitudinal Monitoring
As a Licensed Clinical Psychologist with specialized expertise in psychological and cognitive assessment, Dr. Gaby is equipped to administer and interpret validated cognitive and functional measures, as well as structured assessments of caregiver burden and psychicosocial functioning.
Within the scope of the program and when clinically appropriate, MINDKIND can establish a baseline cognitive, functional, psychosocial, and caregiver-support profile at intake. Depending on the individual's needs and referral goals, assessment may include measures of memory, attention, executive functioning, orientation, functional abilities, mood, and caregiver burden.
This allows the program to look beyond the diagnosis alone and understand how cognitive changes are affecting day-to-day functioning and how the caregiver is managing the demands of care.
Longitudinal reassessment, when appropriate, can help identify meaningful changes over time and provide the referring medical team with additional structured information regarding cognitive and functional trajectory, caregiver capacity, and emerging support needs.
This assessment component is not intended to replace a comprehensive neuropsychological evaluation when one is clinically indicated. Rather, it provides a structured, longitudinal assessment framework within the care-navigation model, allowing concerns to be identified earlier and appropriate referrals or clinical escalation to occur when warranted.
The combination of clinical assessment expertise, dementia care navigation, and caregiver support allows MINDKIND to translate assessment findings into practical care recommendations and individualized navigation priorities.
The dyad
The patient–care partner dyad
A central component of MINDKIND is the recognition that dementia care involves two interconnected individuals: the patient and the care partner.
The patient pathway
Focuses on cognitive and functional changes, safety, care needs, and progression.
The caregiver pathway
Focuses on caregiver capacity, burden, education, coping, and access to support.
Assessing both sides of the dyad allows us to identify concerns earlier and intervene before challenges become crises.
By systematically monitoring patient needs and care partner capacity, MINDKIND can help families remain better prepared as the disease progresses and can identify when additional clinical, community, or supportive services may be needed.
Core services
Core services
MINDKIND provides:
- Cognitive, functional, psychosocial, and caregiver-burden assessment when clinically indicated
- Longitudinal monitoring of cognitive, functional, and caregiver changes
- Post-diagnostic dementia care navigation
- Patient and caregiver needs assessment
- Caregiver education and ongoing coaching
- Education regarding disease progression, communication, and safety
- Care coordination and appointment preparation and reinforcement
- Community resource and service navigation
- Long-term care and transition planning
- Support during changes in level of care
- Identification and escalation of clinical concerns to the appropriate medical team
- Translation of assessment findings into individualized care-navigation recommendations
Beyond neurology
A resource for the broader health system
Although the initial focus is on supporting patients referred from neurology, the model can also serve patients identified through primary care, internal medicine, geriatrics, and other specialties.
This creates an opportunity to engage patients and families earlier in the dementia journey, before needs become more complex, while providing a consistent navigation pathway across the health system.
Proposed partnership
Proposed referral partnership
Patients identified by your practice as appropriate for additional support could be referred directly to MINDKIND. Following referral, MINDKIND would:
Complete an initial patient–care partner assessment
Establishing cognitive, functional, psychosocial, care partner, and resource needs as appropriate.
Develop an individualized navigation plan
Including priorities, recommended resources, follow-up frequency, and care partner-support needs.
Assign the appropriate level of support
Tier 1, Tier 2, or Tier 3, with the ability to adjust the level as needs change.
Provide ongoing navigation and care partner support
Including education, coordination, resource connection, care planning, and longitudinal monitoring.
Escalate clinical concerns appropriately
Concerns requiring medical evaluation would be communicated to the referring provider or appropriate medical team according to the established communication protocol.
Medical diagnosis, treatment, medication management, and clinical decision-making would remain entirely within the patient's medical team.
The goal is simple: to give physicians an additional clinical and navigational resource for the complex, time-intensive needs that arise between medical appointments.
Benefits
Benefits to your organization
A structured navigation partnership may help:
Let's talk
Let's discuss a partnership
Dr. Gaby would welcome the opportunity to meet with you and discuss the program, referral criteria, workflow, communication protocols, and how MINDKIND could complement the care already being provided by your organization.
Contact Dr. GabyMindKind's goal is to create a seamless extension of the care you provide — one that gives patients and families the clinical assessment, education, navigation, and ongoing support they often need after leaving your office.