Adapting the Connect-Home transitional care intervention for the unique needs of people with dementia and their caregivers: a feasibility study

Abstract

Aims:

After leaving skilled nursing facilities (SNF), 20% of people with dementia (PWD) are re-hospitalized within 30 days. We assessed fidelity, acceptability, preliminary outcomes, and mechanisms of the Connect-Home ADRD transitional care intervention.

Design:

A feasibility study of Connect-Home ADRD.

Methods:

The Connect-Home intervention was adapted for dementia-specific needs. PWD and caregiver dyads in 2 SNFs received transitional care. Data sources included interviews with PWD and caregivers and a review of health records.

Results:

19 of 34 eligible dyads (56%) were enrolled. The intervention was feasible (components delivered for >84% of dyads) and acceptable (dyads rated it very helpful and not difficult to use). Connect-Home ADRD adaptations included in-home support to manage symptoms of dementia and unplanned events, such as transition to hospice.

Impact:

Connect-Home ADRD is feasible, acceptable, and merits future research as an intervention to reduce rapid return to acute care following SNF stays.

Introduction

Annually in the U.S., approximately 400,000 people with dementia (PWD) are admitted to a hospital and then transfer to a skilled nursing facility (SNF) for short-term rehabilitation and subsequent transfer to home or other settings of care.¹ Older adults who receive SNF care typically have new acute illness (such as fractures and infections), multiple chronic conditions, and are dependent on family caregivers (spouses, adult children and friends).² When PWD complete care in the SNF and transition to home or assisted living, they commonly experience worsening dementia symptoms, such as confusion and anxiety, which increases safety risks and the need for caregiver support.^3,4 The confluence of these health challenges is associated with acute illness and injury; after discharge from SNF to home, approximately 20% of PWD are rehospitalized within 30 days.^1,5

Transitional care interventions are proven effective to reduce re-hospitalizations for cognitively intact older adults, but have rarely been designed for PWD.⁶ Transitional care is a set of actions designed to ensure the coordination and continuity of health care as patients transfer between settings and health care providers.⁷ Systematic reviews demonstrate that transitional care for cognitively intact older adults leaving the hospital reduces returns to acute care.^8-10 Transitional care of SNF patient and caregiver dyads is an emerging model of care; however, early evidence suggests that it prepares families to implement discharge plans at home and avoid new acute illness and injury.^11,12 Despite the vulnerability of PWD during transitions, transitional care interventions have not been developed to address the needs PWD and their caregivers. Prior research has documented these needs, which include the need for post-discharge support as PWD and caregivers come to terms with the impact of dementia on implementing care plans at home.¹³ In addition, caregivers need guidance on how to manage symptoms of dementia, such as memory loss and resistance to care, which increase the risk for falls and other post-discharge risks.¹³ Thus, research is needed to develop transitional care for PWD in SNFs and their caregivers.

We adapted our SNF transitional care intervention (Connect-Home) to address the unique needs of PWD and caregiver dyads. The Connect-Home intervention and its fidelity, acceptability, and estimated efficacy has been previously reported.^14-16 To adapt Connect-Home, a team of investigators with expertise in geriatrics, dementia, and transitional care applied the Method for Program Adaptation through Community Engagement (MPACE).¹⁷ The team engaged a stakeholder advisory committee, interviewed SNF staff with experience using Connect-Home, identified unmet transitional care needs of PWD and caregiver dyads, and modified the intervention to address unmet needs.^13,18 Collaborating with the stakeholder advisory board, we adapted the content of the intervention to encompass unmet care needs of PWD and caregiver dyads while retaining fidelity to the underlying transitional care process.

The purpose of this study was to conduct a feasibility study of the adapted intervention – Connect-Home for Alzheimer’s Disease and Related Dementias (i.e., Connect-Home ADRD). The aims were to describe (1) staff fidelity to the Connect-Home ADRD intervention protocol, (2) acceptability of Connect-Home ADRD based on patient and caregiver responses to a post-discharge survey, (3) preliminary effectiveness outcomes, based on patient and caregiver responses to post-discharge measures of preparedness to continue care at home and acute care use, and (4) the mechanism through which the intervention addressed the unique transitional care needs of PWD and caregiver dyads.

Materials and Methods

Design

This was a feasibility study of the Connect-Home ADRD intervention.¹⁹ The institutional review board at The University of North Carolina at Chapel Hill approved all study procedures.

Setting and Sample

The study was conducted between August 2021 and February 2022 in the midst of the COVID-19 pandemic. The setting was two SNFs in a not-for-profit nursing home chain in the southeastern U.S. The SNFs had an electronic health record (EHR) system and a monthly SNF patient census of greater than 20 patients per month. The principal investigator (MT) trained study staff in all recruitment and study procedures. To recruit PWD and caregiver dyads, study staff used a Health Insurance Portability and Accountability Act waiver to prescreen records in the EHR system for participant eligibility. Owing to the COVID-19 pandemic and risk mitigation strategies in the SNFs, study staff recruited PWD and caregivers by phone or other remote technology. The criteria for inclusion and exclusion of PWD were: (1) ability to speak English; (2) goal of discharge to home or assisted living; (3) diagnosis of dementia, or SNF staff-rated Brief Inventory of Mental Status score <13 with clinical problems in thinking and memory that consistently interfered with function; and (4) having a caregiver willing to participate. The exclusion criterion for PWD was planned hospital readmission for procedures/treatments in next 30 days. In this low risk study, we used judgement of SNF staff to discover capacity of PWD to consent. When PWD were unable to consent and had a legally authorized representative who was also a family caregiver (i.e., not a court-appointed guardian), we recruited the family caregiver as the proxy respondent to provide consent for both members of the dyad. For each PWD, research staff recruited a caregiver; the inclusion criteria were self-report of assisting the patient at home and the ability to speak English. In recruiting participants, study staff approached the patient first and the caregiver second. All study participants were compensated for completing data collection.

Connect-Home ADRD Intervention

Similar to the Connect-Home transitional care intervention,¹⁷ Connect-Home ADRD is a two-step protocolized transitional care intervention, with pre-discharge and post-discharge components. Connect-Home ADRD includes an additional focus on managing symptoms of dementia, care planning to reduce dementia-related safety risks, and post-discharge support with a Dementia Caregiving Specialist. Existing SNF and home care staff delivered all aspects of Connect-Home ADRD with the exception of the post-discharge phone support, which was delivered by a study employed Dementia Caregiving Specialist, who was an occupational therapist with expertise in care of PWD. Step 1 occurred while the PWD was in the SNF, where SNF staff supported dyads with goal setting for transition needs, care planning to fit goals with family resources, and preparation for discharge, including scheduling physician and home care follow-up, teaching a written transition plan of care, and relaying the discharge plan to the dementia caregiving specialist. In step 2, a home care nurse visited within 24 hours of discharge to reinforce the transition plan and a study-employed Dementia Caregiving Specialist called the caregiver three times over a 4-week period to support implementation of the transition plan. The principal investigator trained SNF and home care staff in one, in-person, 3-hour session with separate training sessions in each SNF. An additional set of four, Zoom-based, 1-hour training session were provided for the Dementia Caregiving Specialist. The focus of staff training was (1) common transitional care needs, including safety, symptom management, function, medication administration, and coordination of care and (2) dementia-specific needs, including recognition of dementia-related safety risks, dementia behaviors and symptom management, and support of caregiver needs. To reinforce the initial staff training, the principal investigator convened “Connect-Home Rounds” over the course of the study. These included three, bi-monthly, 30-minute sessions with SNF staff and three, bi-monthly meetings with the Dementia Caregiving Specialist. In the rounds, we discussed intervention fidelity and strategies to improve or sustain patterns in fidelity. Additional supports for the intervention included modifications to the SNF discharge summary form and the “Connect-Home Planner,” an educational booklet for families that included the individualized transition plan and medication list, dementia care resources, and contact information.

Data Collection

Research staff collected data through a combination of standardized interviews with the caregiver and with the PWD (if able to participate), and abstraction of health records and structured documentation of post-discharge support. Standardized interviews with PWD and caregiver dyads occurred by telephone in 7, 21, and 30 days after SNF discharge.

At 7 days post transition, standardized Interviews with PWD and caregiver dyads in assessed PWD preparedness for discharge using the Care Transitions Measure-15 (CTM-15) and assessed caregiver preparedness for the caregiving role using the Preparedness for Caregiving Scale (PCS).^20,21 The CTM-15 is a 15-item measure of preparedness for discharge, with scores ranging from 0 to 100 and higher scores indicating greater preparedness.²¹ The PCS is a 9-item measure of caregiver preparedness, with scores ranging from 0 to 32 and higher scores indicating greater preparedness and one open question about care needs. Caregiver baseline data also were collected including age, sex, relationship to PWD, living arrangements, education, employment, and number of days per week providing care. At 21 days after the PWD transferred from SNF to home or assisted living, acceptability of the intervention was assessed using an investigator-designed interview guide. Acceptability was defined as satisfaction with the Connect-Home ADRD intervention. Acceptability was measured with a structured interview guide that included three closed questions (i.e., 3-point Likert scaled items) and 3 open questions (i.e., semi-structured interview questions) to assess helpfulness, ease of use, and perceived effectiveness. Finally, in 30 days after SNF discharge, study staff used a standardized instrument to assess emergency department or hospital use. The instrument, used in prior research,^14,15 included three questions: (1) “In the last 30 days, have you been hospitalized,” “In the last 30 days, have you been to an emergency room in a hospital and returned home without hospital admission,” and (3) “In the last 30 days, have you needed to use any urgent care services.” The instrument also included probes to examine the reason and duration of any acute care use. For data collected in 7 and 30 days, study staff recorded responses using data management software. For data collected in 21 days, with permission, study staff digitally recorded responses. The 21-day interview recordings were professionally transcribed.

Data abstraction instruments

First, a standardized instrument was used to abstract data in the SNF electronic health record system in the study SNFs. Baseline characteristics of PWD were abstracted, including age, sex, race, ethnicity, primary diagnosis, diagnosis problem list, hospital and SNF length of stay, and discharge disposition. Based on data in the medical record problem list, Charlson Comorbidity Index scores of PWD were calculated.²² To measure staff fidelity to the intervention protocol, we abstracted five items from the SNF health records of PWD: (1) completing the discharge summary form; (2) hosting a care plan meeting with caregiver attending and attention to cognitive status; (3) scheduling follow-up medical appointments; (4) transmitting records to follow-up clinicians, and (5) start of home care within 24 hours of SNF discharge. Second, a standardized instrument was used to abstract data from the structured documentation of post-discharge telephone support provided by the Dementia Caregiving Specialist. The abstraction tool, mirroring the topic list in the structured documentation template, included PWD and caregiver needs at home, review of the transition plan of care, links to the community, occupational challenges, planning to address needs, and plans for follow-up communication.

Analysis

Descriptive statistics were used to summarize clinical and non-clinical characteristics of PWD and caregivers, staff fidelity to the five elements of the Connect-Home ADRD protocol, and patient and caregiver ratings of Connect-Home ADRD acceptability. Second, to analyze preliminary effectiveness data, we used descriptive statistics and calculated the means and standard deviations for both measures of preparedness for care at home and hospital use. Third, two researchers (JC and MT) used a standardized codebook and independently classified PWD and caregiver responses to the three semi-structured questions in the acceptability survey. After investigators agreed on coding decisions, qualitative content analysis was used to describe patterns in acceptability of the intervention.²³ Finally, two researchers (HM and MT) reviewed data abstracted with the Dementia Caregiving Specialist documentation review instrument and configured data in a data matrix to describe PWD and caregiver transitional care needs and whether and how Connect-Home ADRD addressed those needs.²⁴ Descriptive statistics were used to describe patterns in how Connect-Home ADRD services, such as preparing caregivers to manage symptoms of dementia, influenced dyad outcomes.

Results

Owing to the impact of COVID-19 during the study period, the number of PWD and caregiver dyads who were eligible to participate in the research was smaller than anticipated. Of 284 dyads screened, 250 dyads were ineligible because the patient had an expected discharge from the SNF to long-term care (N=102), did not meet dementia or cognitive impairment criteria (N=101), or no caregiver that was available (N=47). Of 34 eligible dyads, 10 dyads did not consent, and 5 PWD subsequently transitioned to long-term care and were excluded, per study protocol. Thus, a sample of 19 PWD and caregiver dyads was included in the study (56% of eligible) (Table 1). PWD were typically female (79%), white (94.7%), and had an index hospital stay for an acute infection, fracture, or other condition. Caregivers were typically female (68.4%), white (94.7%), and most frequently were related to the PWD as an adult child (79.0%). The discharge disposition was the home of the PWD (57.9%), assisted living (31.6%), or the caregiver’s home (10.5%).

Table 1.

Characteristics of PWD^† and Caregiver Dyads (N = 19)

PWD	N = 19
Age, mean years (SD‡)	85.4 (6.8)
Female, n (%)	15 (79.0%)
Race, n (%)
Black or African American	1 (5.3%)
White	18 (94.7%)
Diagnosis Group, n (%)
Fracture	3 (16.0%)
Infection	7 (36.8%)
Other	9 (47.4%)
Charlson Score, mean score (SD)	5.58 (1.9)
Disposition, n (%)
Own Home	11 (57.9%)
Home of Family	2 (10.5%)
Assisted Living Facility	6 (31.6%)
Length of stay, mean days (SD)	25.9 (11.7)
Caregivers	N = 19
Age, mean years (SD)	61.8 (11.4)
Female, n (%)	13 (68.4%)
Race, n (%)
Black or African American	1 (5.3%)
White	18 (94.7%)
Relation to Patient, n (%)
Daughter	11 (57.9%)
Son	4 (21.1%)
Spouse	2 (10.5%)
Other Family	2 (10.5%)
Living in same home as PWD, n (%)	9 (47.4%)
Education, n (%)
High School	6 (31.58%)
Bachelor’s Degree	4 (21.1%)
More than bachelor’s degree	5 (26.3%)
Employed, n (%)	9 (47.4%)

Footnotes:

^†person with dementia

^‡standard deviation

Fidelity

Staff in both SNFs maintained high fidelity to the intervention protocol over the duration of the pilot study as demonstrated by their delivery of each intervention component to the large majority of participants. Of 19 PWD and caregiving dyads, 18 (94.7%) had a complete transition plan of care, 19 (100%) had a care plan meeting with caregiver attending, 16 (84.2%) had a follow-up medical appointment scheduled before discharge, 19 (100%) had medical records transmitted to follow-up providers, 16 (84.2%) had home care follow-up within 24 hours, and 17 (89.5%) PWD and caregiver dyads had three post-discharge telephone calls with the dementia caregiving specialist within one month of SNF discharge.

Acceptability

Acceptability data were completed for 12 PWD and caregiver dyads. Data were not completed for 3 dyads in which the patient died or was readmitted to the hospital and 4 dyads in which the caregiver was not available for data collection. As described in Table 2, PWD and caregivers reported high acceptability of the intervention. On a 3-point scale, with 1 indicating high acceptability, caregivers reported the intervention was very helpful (M=1.3, SD=0.5), not at all difficult to use (M=1.0, SD=0), and that it prepared them for care at home (M=1.3, SD=0.4). As indicated in Table 2, caregiver responses to open questions in the acceptability survey aligned with these qualitative data. Finally, 4 PWD were able to respond to the survey; all 4 (100%) reported the intervention was very helpful, not at all difficult to use, and effective.

Table 2.

Acceptability (N=12 Caregivers and 5 PWD^† completed the survey)

Item	Scoring	Acceptability
		Mean (SD‡)	Key quotation
How helpful were Connect-Home services?	3-point Likert item, range 1-3. Score of 1 indicating ‘very helpful’	1.3 (0.5)	“It's helpful on several fronts. It's helpful that somebody listens. It's helpful with some of the advice…It feels affirming that you know we're doing the right thing. And it helps to have somebody that's familiar, emotional support.”
How difficult were these services for you to use?	3-point Likert item, range 1-3. Score of 1 indicating ‘not difficult at all’	1.0 (0)	“You were very good about scheduling…It's difficult during COVID and the holidays and caring for someone that has changing needs, big needs. We could be flexible about the time…you moved it a time or two…to reschedule it for another day.”
How well did these services prepare you for care at home?	3-point Likert item, range 1-3. Score of 1 indicating ‘very prepared”	1.3 (0.4)	“They gave me written information about what kind of services they would provide using Connect-Home. Once mom came home, it was all written down. And it told me that they would be providing a home healthcare nurse, a physical therapist,occupational therapist. And they have called, they have set up their appointments, and they've shown up on time.”

Footnotes:

^†person with dementia

^‡standard deviation

Preparedness for Discharge and Acute Care Use in 30 Days

Preparedness for discharge, measured with the CTM-15, was collected from 16 of 19 dyads. Out of a possible score of 100 and higher scores indicating greater preparedness, the mean CTM-15 score was 70.3 (SD=12.0). Preparedness for discharge, measured with the PCS, was collected from 16 caregivers. Out of a possible score of 32 and higher scores indicating greater preparedness, the mean total PSC score was 24.8 (SD=4.4). Of 19 enrolled PWD, one PWD died after transferring to hospice and two had hospital readmissions within 30 days of SNF discharge (both within 24 hours of SNF discharge). One was readmitted for recurrent urinary tract infection, which was potentially preventable. Another was readmitted for myocardial infarction, which likely was not preventable. No PWD had emergency department use without hospitalization in 30 days.

Mechanism of the Intervention

Evidence in the post-discharge document review suggest Connect-Home ADRD promoted effective transitions through three mechanisms. Caregivers increased the size of coverage teams at home, developed communication skills to manage behavioral symptoms of dementia, and were supported after discharge in determining the appropriate level of care for emerging needs of the PWD (Table 3). In the SNF, staff arranged post-discharge care, reconciled medications, and taught strategies to continue care at home or in assisted living. Working with the Dementia Caregiving Specialist, caregivers practiced new communication skills, such as combining visual, verbal, and touch cues to engage the PWD with less distress. Caregivers then used these skills to implement elements of the transition plan, such as using a walker to promote safe ambulation (3 dyads), making dietary changes to improve diabetes care (3 dyads), and creating routines to support home oxygen use (2 dyads).

Table 3.

In-home challenges and Connect-Home ADRD services, (N=17 dyads)

Care Need Addressed	Dyads n (%)	Exemplar Case
Immediate safety risks	8 (47%)	Challenge. The SNF team recommended long term care for PWD; however, the caregiver preferred assisted living. After SNF discharge, the assisted living decided the PWD’s level of confusion and functional needs created safety risks that potentially exceeded services available. Service. The DCS‡ helped the caregiver reflect on overwhelming sadness that she was not able to care for her mother at home or in assisted living. The caregiver developed and implemented a plan to transfer the PWD back to the SNF and on to long term care.
Dementia symptoms	15 (88%)	Challenge. The PWD transferred home where her husband was also seriously ill. The caregiver was one daughter, who was exhausted and frustrated with communication challenges with the PWD. Service. The DCS taught the “Three C’s,” including communication, coverage, and the car (e.g., not driving). The caregiver learned communication strategies, made progress with “resisting behaviors,” and engaged a sibling on the coverage team.
Community supports	10 (59%)	Challenge. The PWD had metastatic cancer and the caregiver preferred SNF discharge to home, where the health of the PWD rapidly declined. Service. The DCS assisted the caregivers with information they used to engage hospice and prevent re-hospitalization.
Caregiver needs	5 (29%)	Challenge. The PWD transferred to home with her granddaughter, who worked and was the mother of a young child. The caregiver was very busy and worried she was not able to balance all her roles and responsibilities. Service. The DCS listened as the caregiver expressed feelings of worry and stress and helped her identify possible adjustments in her caregiving roles. Working with the DCS, the caregiver connected with a friend and fellow dementia caregiver for social support, made plans to increase her coverage team, and established a preferred routine for childcare..

Footnotes:

^§Skilled nursing facility

^‡Dementia caregiving specialist

Dialogue with the Dementia Caregiving Specialist helped caregivers discern the appropriate level of care when the emerging needs of the PWD exceeded the resources in the current setting of care. For example, two caregivers described unmanageable safety risks and chose to transfer a PWD from home or assisted living back to the SNF (and subsequently to long term care); two other caregivers recognized the PWD was nearing death and collaborated with the Dementia Caregiving Specialist to arrange transitions of the PWD from home care to hospice. These changes in level of care were emotional experiences for each caregiver, and the Dementia Caregiving Specialist supported caregivers with empathy and referrals for additional community and professional care.

Discussion

Despite their increased risks for care transitions, minimal research tests transitional care interventions designed to support PWD and caregiver dyads, particularly during transitions from SNF to home or assisted living. In this study, we described the fidelity, acceptability, preliminary outcomes, and mechanism of Connect-Home ADRD. While the phase of research on this intervention is early, the findings support its feasibility, acceptability, and potential to improve caregiver and patient outcomes.

Fidelity to the intervention protocol and acceptability of Connect-Home ADRD were supported in this study. SNF and the Dementia Caregiving Specialist completed each of 6 transitional care tasks for 84-100% of dyads, and participants rated the intervention positively. Prior research described the feasibility of transitional care for PWD and caregivers dyads during transitions from hospital to home.^25-27 Earlier research also demonstrated the feasibility and acceptability of transitional care in SNFs, such as scheduling follow-up appointments and teaching patients and caregivers a written transition plan.^15,28 Expanding this research, our findings demonstrate that combining pre-discharge planning with telephone-based, post-discharge support is an effective strategy to reach busy dementia caregivers at home and provide support that caregivers perceive as helpful and not at all difficult to use. This finding is significant because it demonstrates the viability of a practical strategy to continue education and support services for PWD and caregiver dyads in the first weeks after SNF discharge, when risk to the PWD may be greatest.

Our findings indicate that dyads who received the intervention reported moderate to high readiness for care at home. These findings suggest the intervention met needs identified in earlier research. This included (1) pre-discharge support to prepare for transitions and (2) post-discharge support to identify safety risks, such as the risk for falls in an environment lacking supervision, and learn skills to manage symptoms of dementia, such as resistance to care. Earlier studies demonstrate transitional care with pre- and post-discharge support reduces the risk of acute injury and illness during transitions in care.¹⁰ While the study was not powered to evaluate patient outcomes, only 2 of 19 (10%) of PWD returned to acute care in the subsequent 30 days. Connect-Home ADRD addresses the unique care needs of PWD and is a practical, testable approach to prevent avoidable hospital transfers of PWD following care in SNFs.

These findings must be considered in the context of several limitations. First, the study was conducted in the midst of the COVID-19 pandemic, which limited in-person interactions among staff, PWD and caregivers; and, in our study, reduced the eligible pool of potential SNF patients with plans for transfer from the SNF to home or assisted living. Second, the study was set in a sample of not-for-profit SNFs; thus, future research is needed in a mix of for profit and not-for-profit settings. Third, the sample size was small (19 PWD and caregiver dyads were enrolled) and lacked ethnic and racial diversity, and only included participants who were able to speak in English. Future research must determine the fit of the findings with a more diverse sample and determine the equity of intervention supports across racial and ethnic populations. Finally, this single-arm pilot study did not use randomization or control; thus, the findings are descriptive and cannot demonstrate the efficacy of the intervention. For a feasibility study design, the study has several strengths. First, conducting the study in the midst of the COVID-19 pandemic facilitated a more rigorous test of intervention fidelity than was originally planned. Second, the use of structured interviews with PWD and caregivers and a retrospective chart review facilitated our ability to characterize the acceptability of the intervention and the mechanism through with it addressed unique transitional care needs of PWD.

These findings have several implications for research and practice. They indicate the hypothesis that Connect-Home ADRD prepares dyads for continuing care at home and prevents avoidable hospital transfers. Findings from this study, together with the larger body of evidence for Connect-Home and other SNF transitional interventions, support development of a RCT of Connect-Home ADRD.^12,15,16 In addition, 5 of 24 dyads, who met the criteria for inclusion in the study, were not enrolled because the PWD transferred to long term care. Thus, new transitional care services are needed to engage PWD and caregiver dyads as members of long term care teams, especially in the first weeks after SNF care.^29,30 For example, post-discharge support of the Dementia Caregiving Specialist will prepare caregivers for their roles as partners in long term care and for advocating to implement the transition plan developed in the SNF. Our study findings also suggest that post-discharge support, provided by an occupational therapist, was a feasible approach to address key care needs of PWD and their caregivers.

Our findings also suggest opportunities for nurses and other clinicians to improve the quality of care transitions of PWD and caregiver dyads. One practice is to reconceptualize the overall goal of discharge planning. Many staff currently focus care on “readiness for discharge from the SNF”;^31,32 a more helpful alternative may be to focus on “PWD and caregiver dyad readiness for care in the first two weeks at home.” As demonstrated in earlier research, the mental model of staff influences the focus of care;³³ thus, the focus on readiness for care at home or assisted living will help SNF focus education on how to fit care plans and resources with resources in the discharge setting. A second practice to improve transitions in care will be to recognize that caregivers may not be prepared to fully engage in discharge planning during the SNF stay;^13,18 thus, SNF nurses and other staff must explain the expected impact of dementia symptoms on the transition in care (such as worsened confusion in the first week at home) and extend discharge planning services with post-discharge support. The role of the Dementia Caregiving Specialist in the post-discharge phase may be critical to address the disruptive experience of transitions for PWD. Finally, SNF staff must learn new ways to teach the caregiver skills to communicate with PWD, such as practical guidance to comfort those who experience distress or do not understand or recall the need for clinical interventions such as walkers and diabetes care.⁶ These dyad-centered interventions have the potential to increase the safety of transitions from the SNF to home or assisted living, and to reduce the cyclical use of acute care.

Conclusion

Findings in this feasibility study of Connect-Home ADRD describe an intervention that prepares PWD and caregiver dyads to manage complex transitions in care from SNF to home and assisted living. Findings describe staff fidelity to the intervention protocol and acceptability of practical strategies to support transitions in care, and suggest the hypothesis that Connect-Home ADRD prepares caregivers and prevents avoidable acute care use for PWD. An efficacy trial of Connect-Home ADRD is the logical next step in research.

Abbreviations

PWD

person with dementia

SNF

skilled nursing facility

COVID

Coronavirus disease

MPACE

Method for Program Adaptation through Community Engagement

CTM-15

Care Transitions Measure-15

PCS

Preparedness for Caregiving Scale