Care transitions are the movement of a person from one healthcare setting to another. The hospital-to-home transition is a high-risk period, especially for medication errors and adverse events and for persons with Alzheimer's disease and related dementias (ADRD). There is relatively little research to guide care transition improvement efforts for the ADRD population. An area of particular risk for older adults with ADRD during the hospital-to-home transition is role ambiguity regarding medication management (MM). Role ambiguity in MM occurs when the roles of older adults with ADRD, informal caregivers, and healthcare providers remain without a clear definition of who is responsible for completion of MM-related tasks, such as medication reconciliation. The goal of the current proposal is to (1) identify issues related to role ambiguity regarding medication management that threaten the safety of older adults with ADRD during hospital-to-home transitions, and (2) engage stakeholders to develop a set of strategies specific to ADRD to decrease role ambiguity and support MM during this high-risk transition.
Specific Aim 1 : Identify critical tasks regarding medication management and categorize factors shaping expectations for task distribution during hospital-to-home transitions of older adults with ADRD. We will develop process-flow diagrams of critical MM tasks and categorize factors shaping older adult and informal caregiver expectations for MM task distribution through (1) direct observations and interviews during initial home health visits of recently hospitalized older adults with ADRD and their informal caregivers; (2) photographs of objects used to support MM in the home; and (3) solicited participant diaries followed by post-diary semi- structured interviews with informal caregivers.
Specific Aim 2 : Identify and prioritize stakeholder strategies to manage expectations and distribute tasks to decrease role ambiguity and support successful medication management during hospital-to-home transitions. Guided by a participatory ergonomics approach from the field of human factors engineering, we will form an intervention refinement team (IRT) comprised of older adults with ADRD, informal caregivers, and healthcare providers involved in hospital-to-home transitions. The IRT will meet to use findings from the hospital- to-home process-flow diagram (Aim 1) to develop strategies and rate each strategy according to (1) importance to reducing role ambiguity, (2) likelihood of effectiveness in supporting MM, and (3) level of actionability. The long-term goal of our research is to develop, evaluate, and disseminate best practices to deliver optimal health care to older adults with ADRD in all stages of disease as they transition across healthcare settings. Completion of these aims will result in a stakeholder-informed set of strategies to support MM. Study findings will build a foundation for future work to develop and test a behavioral or technological solution to address unmet needs and safety risks during the hospital-to-home transition for older adults with ADRD.

Public Health Relevance

Older adults with Alzheimer's disease and related dementias (ADRD) and their informal caregivers face challenges managing medications, especially when coming home from the hospital. Many older adults with ADRD require home nursing services after hospital discharge, and these older adults are at are at high risk of returning to the hospital within a short time frame. The overall goal of the proposed study is to engage older adults, their caregivers, and home health nurses in an interactive process to develop strategies to address unmet needs related to medication management when coming home from the hospital.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Small Research Grants (R03)
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Special Emphasis Panel (ZAG1)
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Salive, Marcel
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Johns Hopkins University
Internal Medicine/Medicine
Schools of Medicine
United States
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