Dementia

Five Evidence-Based Practice Recommendations for Successful Transitions in Care

Five evidence-based interventions have been identified for easing the transition of care for individuals with dementia and their caregivers, according to the results of a new review.1

Although there are many transitions of care already established, the core elements of successful transitions among individuals with dementia, specifically, were lacking.

To conduct their review, the researchers evaluated published literature about interventions targeting transitions in care for individuals with dementia and their caregivers.

The results of their analysis showed that 5 interventions can postpone/prevent or reduce care transitions.

Overall, the most effective approaches for this population include:

  1. Educate patients with dementia and their family caregivers on the common transitions, including across care settings, within care settings, or from one team of clinicians to another.
  2. Ensure open and timely communication of information during transitions, including standardizing ways to share medical records and advance care planning forms between patients, caregivers, and providers.
  3. Revisit the preferences and goals for care, including treatment preferences, advance directives, and social and living situations, while transitioning care.
  4. Create strong interprofessional collaborative team environments to support persons living with dementia during transitions in care.
  5. Use evidence-based models of care to avoid unnecessary delays in transition (ie, hospitalization or emergency department visits).

“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.2

“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.”2

—Amanda Balbi

References:

  1. Hirschman KB, Hodgson NA. Evidence-based interventions for transitions in care for individuals living with dementia. 2018;58(Suppl 1):S129-140. https://doi.org/10.1093/geront/gnx152.
  2. Core elements identified for successful transitions in care for older adults with dementia [press release]. Philadelphia, PA: Penn Nursing Science; March 16, 2018. http://www.nursing.upenn.edu/live/news/1025-core-elements-identified-for-successful.