Transitional Care To Home And Dementia

Mar 28

31 Jan Transitional Care To Home And Dementia

Many people who receive care in nursing homes for short-term rehabilitation have dementia. About ⅓ have a formal diagnosis and many more than that have documented problems with memory and thinking. After a hospitalization and a stay in a nursing home, many people with dementia then transition home with caregivers. There are a number of challenges these patients and their caregivers face in terms of developing and implementing a plan to manage needs related to healthcare at home. A team based at the University of North Carolina recently completed a clinical trial to test an enhanced discharge to home program for people with dementia and their caregivers. The Connect-Home trial results appear in the January 2023 issue of the Journal of the American Geriatrics Society.

Key points

People with dementia and their caregivers may face multiple challenges when transitioning from SNF to home, including managing symptoms and connection to community supports.

The Connect-Home trial tested a supported discharge program, which included staff educating families and patients and home health coordination, with over 300 patients with dementia.

The trial did not show positive results but was disrupted by COVID; highlights important lessons about the challenges of conducting research in nursing homes including the need for buy-in by all stakeholders.

The transitional care intervention includes tools, training, and technical assistance for (1) SNF staff to create individualized transition plans and engage in caregiver training and (2) a home care nurse to help the patient and caregivers implement transition plans at home. The study measured primary goal of the study was to measure the impact of the intervention on SNF patient and caregiver preparedness for care at home. They also measured other impacts on caregivers and re-hospitalization rates after discharge from the SNF.

The intervention was built to address unique care needs during transitions for persons with dementia and their caregivers. Before launching their trial, the team interviewed stakeholders to learn about key issues in these transfers. They report that four care needs were identified: 1) persons with dementia and caregivers may not be ready to fully engage in dementia care planning during the SNF stay; 2) caregivers are unprepared to manage symptoms related to dementia at home; 3) SNF staff struggle to connect people with community supports; and 4) caregivers receive little support to address their own needs. Specifically, SNF staff expressed concern that caregivers and persons with dementia did not engage in developing plans around safety, for example fall risks, driving, and medication management. In addition, staff noted an under-recognition of the need for 24 hour supervision and support.

Connect-Home was compared to standard discharge planning in a randomized controlled trial. The setting was six SNFs and six home health offices in one agency. They enrolled 327 patients discharged from SNF to home and each of their caregivers. Primary outcomes measured at 7 days included patient and caregiver measures of preparedness for care at home, the Care Transitions Measure-15 (patient) and the Preparedness for Caregiving Scale (caregiver). Secondary outcomes measured at 30 and 60 days included the McGill Quality of Life Questionnaire, Life Space Assessment, Zarit Caregiver Burden Scale, Distress Thermometer, and self-reported number of patient days in the ED or hospital in 30 and 60 days following SNF discharge. Unfortunately, they did not see an improvement in patient or caregiver outcomes in the intervention group. The onset of COVID-19 disrupted many research programs, including this one. They had to pause for several months and then make several adaptations to the project. Additional analyses accounting for the effects of COVID did show positive impacts on patient preparedness for discharge and lower acute care days in the intervention group.

Overall, unlike some other trials evaluating care transition interventions, this rigorous trial did not show improvements for patients and caregivers. A multi-part intervention like this requires the participation of many people – nursing home staff, home health staff, patients and caregivers. The pandemic had a serious impact on fidelity in this trial, meaning how closely everyone was able to follow the full protocol and implement all of the pieces. This trial highlights the challenges of conducting research studies in complex healthcare environments and the need for true buy-in and participation from nursing home staff and leadership to pull it off. While this trial was not positive, the transitional care practices tested are considered “best practice” – the question that still exists is how to implement them in a consistent and targeted manner.

References

Toles M, Leeman J, Gwyther L, Vu M, Vu T, Hanson LC. Unique Care Needs of People with Dementia and Their Caregivers during Transitions from Skilled Nursing Facilities to Home and Assisted Living: A Qualitative Study. J Am Med Dir Assoc. 2022 Sep;23(9):1486-1491. doi: 10.1016/j.jamda.2022.06.021. Epub 2022 Aug 1. PMID: 35926571.

Toles M, Leeman J, McKay MH, Covington J, Hanson LC. Adapting the Connect-Home transitional care intervention for the unique needs of people with dementia and their caregivers: A feasibility study. Geriatr Nurs. 2022 Nov-Dec;48:197-202. doi: 10.1016/j.gerinurse.2022.09.016. Epub 2022 Oct 20. PMID: 36274509; PMCID: PMC9749405.

Toles M, Preisser JS, Colón-Emeric C, Naylor MD, Weinberger M, Zhang Y, Hanson LC. Connect-Home transitional care from skilled nursing facilities to home: A stepped wedge, cluster randomized trial. J Am Geriatr Soc. 2023 Jan 10. doi: 10.1111/jgs.18218. Epub ahead of print. PMID: 36625769.