An integrative review of measures of transitions and care coordination for persons living with dementia and their caregivers

Abstract

IntroductionHigh rates of hospital visits and readmissions are common among persons living with dementia, resulting in frequent transitions in care and care coordination. This paper identifies and evaluates existing measures of transitions and care coordination for persons living with dementia and their caregivers.MethodsThis integrative review builds off a prior review using a systematic search of online databases (PubMed, EBSCO, CINAHL, PsycInfo, and Scopus) to identify records and locate reports (or articles) that use measures of care transitions and care coordination. Identified measures were compared to the Alzheimer's Association's Dementia Care Practice Recommendations to evaluate strengths and weaknesses of the measure in this population, such as if measures were person‐ and family‐centered.ResultsSeventy‐one reports using measures of transitions in care and care coordination for persons living with dementia and their caregivers were identified. There were multiple measures identified in some reports. Three main areas of measures were classified into: identification of the population (3 measures, 8 reports), transitional care and care coordination delivery (14 measures, 17 reports), and transitional care and care coordination outcomes (e.g., health‐care use, cost, and mortality; 17 measures, 60 reports). A strength of the three main areas of measures was that a portion of the measures were person‐ and family‐centered. Variability in the operational definitions of some measures and time intensiveness of collecting the measure (e.g., number of items, the time it takes to complete the items) were common weaknesses.DiscussionTransitions and care coordination measures are varied across studies targeted at persons living with dementia and their caregivers. Existing measures focus heavily on outcomes, specifically health‐care resource use, and cost, rather than the elements of transitional care or care coordination. Future measure development focused on care transitions and service coordination is needed.

Healthcare and social care professionals’ experiences of respite care: a critical incident study

“…Poor communication during transitions in care has been associated with adverse outcomes for patients (Coleman, 2003 ; Naylor et al, 2011 ) and the logistical issues resulting from communication failures compromise the individualization of care, a core component of quality healthcare. In continuity, the findings parallel research indicating that disruptions in care routines negatively impact patient well-being (Hirschman et al, 2023 ). The absence of routine can be particularly disorienting for persons with cognitive impairments, such as dementia, and can exacerbate symptoms such as agitation, leading to increased distress (Fauth & Gibbons, 2014 ).…”