Overview
This study is a parallel arm, cluster randomized trial (CRT) to test the efficacy of Connect-Home ADRD, a transitional care intervention focusing on Skilled Nursing Facility (SNF) patients with Alzheimer's disease and dementias and their caregivers during transitions from SNFs to home, assisted, living, and long-term care. The primary hypothesis is that the intervention will reduce caregiver strain (Aim 1) and patient neuropsychiatric symptoms (Aim 2).
Description
Connect-Home ADRD is a Donabedian-guided intervention that introduces new structure and processes to support Skilled Nursing Facility (SNF) staff delivery of transitional care for transitions to home, assisted living, or long-term care, and post-discharge transitional care by the Dementia Caregiving Specialist (DCS).
The research objective is to test the efficacy of Connect-Home ADRD, a transitional care intervention, targeting Skilled Nursing Facility (SNF) patients with Alzheimer's disease and related dementias (ADRD) and their primary caregivers who discharge home and other settings of care. The study will be set in 12 North Carolina SNFs and in the patient's discharge destination (during intervention periods only). Using a cluster-randomized trial design, twelve SNFs will be randomly allocated to an intervention group (N=6 SNFs) and to a control group (N=6 SNFs) by a study statistician masked to SNF identity. 360 dyads of SNF patients with ADRD and caregivers will be enrolled in 12 SNFs.
Eligibility
Inclusion Criteria:
- Patients
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- Ability to speak English
- Goal of discharge to home, assisted living, or long-term care
- Diagnosis of dementia
- Having a caregiver willing to participate
- Caregivers
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- Ability to speak English
- Legally authorized representative (LAR) who also provides support for the person with ADRD
Inclusion criteria for SNFs:
- Location within 120 miles of UNC-Chapel Hill
- Admission of at least 75 SNF patients per year
Exclusion Criteria:
- Patients
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- Planned hospital readmission for procedures or treatments within 30 days post enrollment.
- Caregivers
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- LAR is a court-appointed guardian.