GEAR 2.0 Priorities – Care Transitions
Approximately 50 percent of people living with dementia (PLWD) are discharged to their homes after receiving emergency department (ED) care, but approximately 40 percent of PLWD discharged will experience an adverse event (ED revisits, other hospitalizations, or death) in the 30 days following discharge—a rate significantly higher than for those without dementia. The Care Transitions Work Group (WG) decided that the scope of its PICO-driven literature review would:
- focus broadly on studies addressing cognitive impairment (not studies detecting only dementia, because in some studies dementia diagnoses are unknown), and
- target studies that address the ED-to-home or ED-to-community transitions.
The Care Transitions WG identified two key PICO questions to the literature review.
- PICO-1: What interventions delivered to ED patients with impaired cognition and their care partners improved ED discharge transition?
- PICO-2: What measures of quality ED discharge transitions are important to varying groups of ED patients with impaired cognition and their care partners?
Top Research Priority Areas
The top voted care transitions research priority areas ranked during the 2021 GEAR 2.0 Consensus Conference based on the scoping reviews are as follows:
- What improves outcomes of ED-to-community care transitions among ED patients with impaired cognition and their care partners (e.g., system, program operations, individual/care-partner strengths/needs) and how can these be personalized for vulnerable pops?
- What matters most to ED patients with impaired cognition and their care partners during the ED-to-community transition and how can these priorities best be measured?
- What barriers, facilitators, and strategies, specifically leveraging implementation science methods, influence engagement, uptake, and success of care transition interventions, including national guidelines, policies, and best practices?
- How can care partners and community organizations be best engaged and empowered to improve ED-to-community care transitions?
- How can communication quality surrounding ED-to-community transitions be optimally measured?