One in five patients is rehospitalized within 30 days of discharge, and dementia is known to increase this risk, yet there are no evidence-based interventions available to improve transitions or decrease rehospitalizations for patients with dementia. Poor quality care transitions from the hospital to the community cause care discontinuity, patient dissatisfaction, rehospitalizations, and serious medication errors resulting in delirium, falls or functional loss-the most common, preventable post-hospital complications in dementia. Available evidence-based transitional care interventions, which use education-focused home visits to support patients after hospitalization, improve medication management, patient health and reduce rehospitalizations. However, these interventions exclude patients with dementia, even though some dementia patients may still benefit from certain educational approaches like spaced retrieval. Additionally, their home-visit design makes these interventions unacceptable to over 45% of patients, extremely costly and inappropriate for patients who live beyond the practical geographic reach of hospital-based staff. As such, there is a critical need for low-cost, phone-based interventions to improve transitional care for all patients with dementia. In response, we developed the Coordinated-Transitional Care (C-TraC) Intervention-a novel, low-cost, phone-based intervention designed to improve transitional care quality, rehospitalizations and patient/caregiver outcomes in hospitalized patients with dementia discharged to community settings. On pilot testing, intervention patients experienced 1/3 fewer rehospitalizations than a comparable baseline group, producing an estimated savings of $1,225 per patient net of intervention costs. Patients and caregivers reported that the intervention was highly acceptable, decreased their caregiving stress and improved their medication management skills. Due to its low-cost and patient-centered design, the C-TraC intervention has the potential to rapidly disseminate. Our goal is to conduct a single-blind, prospective, randomized-controlled clinical trial to determine C-TraC's impact on 30-day rehospitalizations (primary outcome), caregiver stress, and the patient- centered post-hospital outcomes of delirium prevention/resolution, functional maintenance/recovery and falls prevention in patients with dementia discharged from the hospital to the community. This proposed work directly aligns with transitional care research goals outlined by The National Plan to Address Alzheimer's Disease (Strategies 2.F, 3.B), the National Alzheimer's Project Act (NAPA) and the NIA.
One in five patients is rehospitalized within 30 days of discharge, and dementia is known to increase this risk, yet there are no evidence-based interventions available to improve transitions or decrease rehospitalizations for patients with dementia. In response, the proposed research will determine the impact of the Coordinated- Transitional Care (C-TraC) Intervention-a novel, low-cost intervention designed to improve transitional care quality, rehospitalizations and patient/caregiver outcomes in hospitalized patients with dementia discharged to community settings. This proposed work directly aligns with research goals outlined by The National Plan to Address Alzheimer's Disease (Strategies 2.F, 3.B), the National Alzheimer's Project Act (NAPA) and the National Institute on Aging.
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