National Plan to Address Alzheimer's Disease: 2018 Update. Strategy 2.F: Ensure that People with Alzheimer's Disease and Related Dementias Experience Safe and Effective Transitions between Care Settings and Systems


People with AD/ADRD have higher rates of emergency room visits and hospitalizations, two settings where they are vulnerable to stress, delirium, and unnecessary complications. A transition between providers and care settings is a complex time of care delivery for all people, but especially for frail elders or other people with AD/ADRD who often have multiple chronic conditions. Transitions include moves into acute care hospitals, from hospitals to post-acute care settings such as skilled nursing facilities or the home, or from nursing facilities to hospitals. People with AD/ADRD are at high risk of adverse events due to poor communication and other care process deficiencies during transitions and need support to help them determine the best timing for transition and site of care.

(UPDATED) Action 2.F.1: Implement and evaluate new care models to support effective care transitions for people with Alzheimer's disease and related dementias

CMS's Comprehensive Primary Care Plus Model includes about 6% of beneficiaries with dementia, where providers can receive enhanced fees for care coordination and support for beneficiaries with dementia. CMS is also hosting a "National Care Transitions Week" in 2018 to gather stakeholder input.

ACL's state dementia system grants are all required to include a care transitions component and all grantees are required to evaluate the effectiveness of their programs. Numerous models of care transitions interventions are presently being implemented through ACL's community project, all of which include collection of outcome data and will include a programmatic evaluation upon completion of the grant period.

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