Annually in the U.S., approximately 400,000 people with dementia (PWD) are admitted to a hospital and then transfer to a skilled nursing facility (SNF) for short-term rehabilitation and subsequent transfer to home or other settings of care.1 Older adults who receive SNF care typically have new acute illness (such as fractures and infections), multiple chronic conditions, and are dependent on family caregivers (spouses, adult children and friends).2 When PWD complete care in the SNF and transition to home or assisted living, they commonly experience worsening dementia symptoms, such as confusion and anxiety, which increases safety risks and the need for caregiver support.3,4 The confluence of these health challenges is associated with acute illness and injury; after discharge from SNF to home, approximately 20% of PWD are rehospitalized within 30 days.1,5

Transitional care interventions are proven effective to reduce re-hospitalizations for cognitively intact older adults, but have rarely been designed for PWD.6 Transitional care is a set of actions designed to ensure the coordination and continuity of health care as patients transfer between settings and health care providers.7 Systematic reviews demonstrate that transitional care for cognitively intact older adults leaving the hospital reduces returns to acute care.8, 9, 10 Transitional care of SNF patient and caregiver dyads is an emerging model of care; however, early evidence suggests that it prepares families to implement discharge plans at home and avoid new acute illness and injury.11,12 Despite the vulnerability of PWD during transitions, transitional care interventions have not been developed to address the needs PWD and their caregivers. Prior research has documented these needs, which include the need for post-discharge support as PWD and caregivers come to terms with the impact of dementia on implementing care plans at home.13 In addition, caregivers need guidance on how to manage symptoms of dementia, such as memory loss and resistance to care, which increase the risk for falls and other post-discharge risks.13 Thus, research is needed to develop transitional care for PWD in SNFs and their caregivers.

We adapted our SNF transitional care intervention (Connect-Home) to address the unique needs of PWD and caregiver dyads. The Connect-Home intervention and its fidelity, acceptability, and estimated efficacy has been previously reported.14, 15, 16 To adapt Connect-Home, a team of investigators with expertise in geriatrics, dementia, and transitional care applied the Method for Program Adaptation through Community Engagement (MPACE).17 The team engaged a stakeholder advisory committee, interviewed SNF staff with experience using Connect-Home, identified unmet transitional care needs of PWD and caregiver dyads, and modified the intervention to address unmet needs.13,18 Collaborating with the stakeholder advisory board, we adapted the content of the intervention to encompass unmet care needs of PWD and caregiver dyads while retaining fidelity to the underlying transitional care process.

The purpose of this study was to conduct a feasibility study of the adapted intervention – Connect-Home for Alzheimer's Disease and Related Dementias (i.e., Connect-Home ADRD). The aims were to describe (1) staff fidelity to the Connect-Home ADRD intervention protocol, (2) acceptability of Connect-Home ADRD based on patient and caregiver responses to a post-discharge survey, (3) preliminary effectiveness outcomes, based on patient and caregiver responses to post-discharge measures of preparedness to continue care at home and acute care use, and (4) the mechanism through which the intervention addressed the unique transitional care needs of PWD and caregiver dyads.