Core Elements Identified for Successful Transitions in Care for Older Adults with Dementia
For older adults with multiple chronic conditions and complex care requirements, transitioning between levels of care and across care settings is common. It is well understood that high-quality transitional care is important for both the well-being of the older adult and for family caregivers. While there has been an increased focus on person-centered models of care transition for cognitively intact older adults from hospital to home, little is known about the core elements of successful transitions in care specifically for persons with dementia.
To provide practice recommendations for improving transitions in care for older persons living with dementia, two researchers from the University of Pennsylvania School of Nursing (Penn Nursing) completed a review of the literature which revealed only seven evidence-based interventions that target transitions in care for this population of older adults living with dementia. The study, “Evidence-Based Interventions for Transitions in Care for Individuals Living With Dementia,” was published in The Gerontologist earlier this year. The findings of this review are part of the latest Dementia Practice Recommendations put out by the Alzheimer’s Association.
“Most research on transitions in care has either not focused on older adults living with dementia or has excluded this population. Consequently, clinicians are not trained in best practices for transitional care for this population, organizations do not have evidence-based processes available to facilitate smooth care transitions, and persons living with dementia and their caregivers are not aware of the likelihood of common care transitions,” says lead-author Karen B. Hirschman, PhD, MSW, the NewCourtland Term Chair in Health Transitions Research and Research Associate Professor.
The review of the literature revealed five essential themes for consistent and supported care transitions for persons living with dementia and their caregivers that were used to develop the following practice recommendations:
- Prepare and educate persons living with dementia and their family caregivers about common transitions in care.
- Ensure complete and timely communication of information between, across, and within settings.
- Evaluate the preferences and goals of the person living with dementia along the continuum of transitions in care.
- Create strong inter-professional collaborative team environments to assist persons living with dementia and their caregivers as they make transitions.
- Initiate/use evidence-based models to avoid, delay, or plan transitions in care.
“Our review suggests that the best outcomes for persons at high risk for care transitions, such as individuals living with dementia, are associated with care that is person-centered in that it is coordinated, responsive, and tailored to individual’s and family’s needs and preferences,” says co-author Nancy A. Hodgson, PhD, RN, FAAN, the Anthony Buividas Term Chair in Gerontology and Associate Professor of Nursing. “Thus, best practice recommendations involve successfully connecting medical, social, and supportive care professionals and caregivers over the course of dementia to achieve person-centered outcomes in transitions between care settings.”
Putting these five recommendations into practice will require a shift in current health care policies and practices, say the researchers. The growing need for services that reduce unnecessary transitions or support necessary transitions can act as drivers for program innovation.
This paper was published as part of a supplement in The Gerontologist sponsored and funded by the Alzheimer’s Association. The complete set of “Dementia Care Practice Recommendations” were presented on February 14, 2018 on Capitol Hill in the Russell Senate Office Building, Kennedy Caucus Room, Washington, D.C.