Transitional Care: Focus on Dementia Needed

More and more the literature is indicating that transitional care is beneficial to care and promotes cost savings. In relationship to Medicare and readmission penalties, transitional care has been found to help reduce readmissions with a focus on diagnoses of heart disease, diabetes, etc. And, a recent article in by Health Leaders Media describes research on Medicaid patients and transitional care in North Carolina, and the positive results to both patients and finances.

However, what transitional care thus far has failed to adequately address is a patient who is at high risk for readmission and has dementia. Transitional care programs have been silent to the unique needs of individuals with dementia and their caregivers.

Hospital patients with dementia returning home require the engagement and training of an identified caregiver. An ongoing support system also is needed for families and caregivers to cope with the transitions, changes in behaviors and functional losses that occur as the disease progresses. Providing education, identifying and securing support systems and resources are items to be addressed upon admission to acute care – not at discharge.

Many hospital patients with Alzheimer’s disease or a related dementia do not return home but are transferred to a long-term care environment. More than 50% of all residents in long-term care settings are cognitively impaired. Despite this reality, assisted living and nursing facilities also suffer from a lack of dementia knowledge and hence remain a major source of hospital readmissions.

As veterans in dementia care, The Gilster Group will work with your organization to develop dementia-specific transitional care protocols and systems using proven best practices in dementia care, refined during decades of experience.

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