National Institute on Aging 5U19AG078105-03

Nurse Led Telephonic Care

This NIH-funded project implements a nurse-led telephonic care intervention to reduce emergency department visits and hospitalizations among people living with dementia. It involves a pragmatic trial across 40 EDs to evaluate effectiveness and health equity impacts.

Description

The emergency department (ED) is often the care setting of last resort, and is ill suited to provide care for people living with dementia (PLWD) and their care partners. Many ED visits, which are for ambulatory-care-sensitive or acute exacerbations of chronic conditions, pain, behavioral and psychological symptoms of dementia (BPSD), and care partner strain are addressable if intervened upon in the community. Significant inequity in access to effective outpatient or home-based care further exacerbates who unnecessarily ends up in the ED. ED visits are also a significant indicator for serious illness in PLWD; 43.1% will have subsequent ED visits and 31.9% will die within one year. Telephonic nurse-led, interdisciplinary transitional and palliative care is a cost-effective, patient-centered modality shown to both reduce inequities and ED visits. This project will implement Aliviado Dementia Care-Telephonic Edition, an evidence-based nurse-led telephonic transition and palliative care intervention tested end-to-end and widely disseminated in other modalities. The intervention will follow PLWD for 6 months, focusing on care transitions, assessing and managing BPSD, care partner strain, social determinants of health and social needs, and conversations about serious illness. The study will optimize the telephonic intervention for use with other interventions (ED Care Redesign and Community Paramedic-led Transitions) in two EDs to ensure effective coordination. A 3-arm embedded pragmatic cluster randomized trial will be conducted using Medicare claims data to test whether nurse-led telephonic care reduces ED visits and hospitalizations, and increases healthy days at home. The intervention will be implemented in 40 EDs, tested alone and in combination with other interventions. Additional analysis will examine patient- and organization-level factors, including health inequities, influencing implementation and outcomes.

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