Care transitions are very common among nursing home (NH) residents with dementia, and many of these are deemed avoidable. Multiple hospitalizations at any point during NH stays, and particularly at the end of life, would be markers of poor care, diminished quality of life, and inefficient use of resources. There is an urgent need to identify individuals with dementia who are at highest risk of harmful care transitions, identify care deficiencies that contribute to these transitions, and develop interventions that can be targeted to individuals with greatest risk. Prior research provides some understanding of transition patterns older adults experience; however, there are several gaps: (a) transition studies among residents with dementia have not considered dementia severity or the relationship between dementia and co-morbidities; (b) the majority of research efforts have focused on singular care transitions in cross-sectional studies; (c) research has tended to emphasize the number of transitions without considering the length of stay in each setting; (d) most studies have not tracked changes in health over time, and no studies to our knowledge have applied mixture growth models to identify care trajectories for individuals with dementia; and (e) few studies have attempted to link quality of care with likelihood of care transitions or transition patterns over time. In this proposed study, we will address these gaps and model care transitions between NH, hospital, emergency department, community, and death for a cohort of NH dual-eligible (Medicaid and Medicare) residents aged 65+ with dementia. The study cohort will consist of approximately 8,500 residents who received NH care in Minnesota beginning in 2014 and followed for up to 5 years through 2019, to pursue three specific aims: 1) identify the main care trajectories in a cohort from entry to death (or censoring), 2) determine the impact of dementia severity and co-morbidities in influencing the patterns of care trajectories, and 3) examine the associations between markers of quality in NH care (general and end-of-life quality measures) and the most common trajectories. This study is innovative in: 1) identifying key characteristics of high-risk groups with dementia in care transitions for intervention; 2) a more-complete understanding of patterns and determinants of care transitions among older adults with various levels of dementia; 3) analyzing the relationship between dementia and co- morbidities; 4) comparing the similarities and differences in care transitions between short- and long-stay residents with dementia; and 5) investigating whether residents with dementia living in NH with poor quality performance would experience more acute care transitions compared with those in facilities with better quality performance. The longitudinal design of this proposed study will provide direction to policy and practice to permit evidence-based decision-making regarding optimal movement during an episode of dementia care.
Multiple care transitions among residents with dementia at any point during their nursing home stays, and particularly at the end of life, are markers of poor care, diminished quality of life, and inefficient use of resources. A clear and urgent need exists to identify key characteristics of high-risk groups in care transitions for intervention, such as characteristics of older adults with dementia who frequently transition back and forth between nursing home and hospital. If certain quality measures are identified to be directly related to care transitions, quality reform efforts based on improving performance on these significant measures may result in large-scale reductions in avoidable care transitions, improvement in residents' quality of life, and overall reduction in healthcare expenditures.
