Alzheimer Disease, Alzheimer's Disease Related Dementia
Conditions
Keywords
Dementia
Brief summary
The purpose of this study is to improve the care of persons living with dementia (PLWD) and their informal care partners by addressing emergency and post-emergency care through different combinations of three PLWD-care partner dyad focused interventions. The primary aims are to use coaching to help connect PLWD and their care partners with community support and services to improve transitional care, quality of care, care satisfaction and reduce future ED visits and hospitalizations.
Interventions
BEHAVIORALEmergency Care Redesign (ECR)
Care Process Redesign: Care process redesign with a shared structured worksheet for data gathering, standardized assessment and referral. Education of all providers (Physician, Nurse, and Social Work Champion) on new processes at huddles and via on-line training, smart phone-compatible animated videos, faculty meetings, e-mail and from ED champions on shift CDS System: Alerts and new workflow to refer the dyad to social work or care manager. Continued use throughout study period and beyond Follow up: Within 72 hours of ED visit if discharged home Social Work Champion will have a single phone call. Triadic telephone encounter to ensure understanding of discharge plan, medication management and connection to community services
BEHAVIORALNurse-led Telephonic Care (NLTC)
Telephonic support for dyad for safe ED to home care transition, and to enhance knowledge and management of AD/ADRD and co-morbid conditions. First call to dyad within 72 hours of index ED visit from Registered nurses. Each call \~30 minutes depending on needs and willingness of dyad. Calls also occur at 14 days, and at least monthly thereafter for 6 months. Dyad or nurse can initiate additional as-needed calls and coordinate care and care needs with other providers
BEHAVIORALCommunity Paramedic-led Transitions Intervention (CPTI)
Community paramedics to provide coaching with dyad to improve medication management, outpatient follow up, understanding of red flags necessitating medical care. Home visit within \~5 days of index ED visit. One home visit and three telephone encounters over 30 days
Sponsors
NYU Langone Health
National Institute on Aging (NIA)
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
66 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* patients age 66 and older * have at least one ICD-10 visit diagnoses for Alzheimer's Disease or Alzheimer's Disease Related Dementias (AD/ADRD) from an inpatient or outpatient encounter within the last 3 years of the ED visit and are discharged (observation patients included)
Exclusion criteria
* patients who are under 66 years old
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Number of Emergency Department (ED) revisits | Up to 30 days |
Secondary
| Measure | Time frame |
|---|---|
| Number of ED revisits | Up to 14 days |
| Number of hospitalizations | Up to 14 days |
| Number of healthy days at home | Up to 6 months |
Countries
United States
Contacts
PRINCIPAL_INVESTIGATORJoshua Chodosh, MD
NYU Langone Health
Outcome results
None listed