The DOI matches its Crossref record; 56 of the 56 references it cites were found in a registry or an index.
Evidence-Based Interventions for Transitions in Care for Individuals Living With Dementia
Abstract
Background and Objectives: Despite numerous, often predictable, transitions in care, little is known about the core elements of successful transitions in care specifically for persons with dementia. The paper examines available evidence-based interventions to improve the care transitions for persons with dementia and their caregivers. Research Design and Methods: A state-of-the-art review was conducted for research published on interventions targeting transitions in care for persons living with dementia and their caregivers through January 2017. Results: Our review revealed seven evidence-based interventions to postpone/prevent or reduce care transitions specific to persons living with dementia. Effective approaches appear to be those that involve the individual and caregiver in establishing goals of care, educate the individual and caregiver about likely transitions in care; provide timely communication of information about the individual, create strong inter professional teams with competencies in dementia care, and implement evidence-based models of practice. Discussion and Implications: Five essential features for consistent and supported care transitions for persons with dementia and their caregivers are recommended. Findings reinforce the need for additional research and adaptation of evidence-based transitions in care interventions.
Overview
Integrity signals
Registry
Cites
Statistics
Verification
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In the citing paper
“In the wider literature, most transitional care interventions have not focused on dementia [103]; indeed, patients with dementia or complex care needs are often excluded from transition research [104].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [103]
In the citing paper
“Research investigating dementia-specific hospital-to-home interventions is in an early stage, and as older adults with MLTCiD have an increased risk of harm during transitions, their inclusion in interventions is important to understand how we can support their needs [103, 104].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [103]
In the citing paper
“Research investigating dementia-specific hospital-to-home interventions is in an early stage, and as older adults with MLTCiD have an increased risk of harm during transitions, their inclusion in interventions is important to understand how we can support their needs [103, 104].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [103]
In the citing paper
“Breakdowns in transitions of care between health care providers and settings limit high‐quality, comprehensive and/or appropriate dementia care, as evidenced by an increase in emergency room visits and hospitalizations and decreased quality of life. 975”
From 2024 Alzheimer's disease facts and figures (2024) · cites this paper as [975]
Citations
Cites
A typology of reviews: an analysis of 14 review types and associated methodologies
Grant, M. J., & Booth, A. (2009) · Health Information & Libraries Journal · doi:10.1111/j.1471-1842.2009.00848.x · Cited by 10,817
The Care Transitions Intervention: Results of a Randomized Controlled Trial
Coleman, E. A., Parry, C., Chalmers, S., & Min, S.-J. (2006) · Archives of Internal Medicine · doi:10.1001/archinte.166.17.1822 · Cited by 1,937
Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., & Schwartz, J. S. (1999) · JAMA · doi:10.1001/jama.281.7.613 · Cited by 1,831
A Reengineered Hospital Discharge Program to Decrease Rehospitalization
Jack, B. W., Chetty, V. K., Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E., Forsythe, S. R., O'Donnell, J. K., Paasche‐Orlow, M. K., Manasseh, C., et al. (2009) · Annals of Internal Medicine · doi:10.7326/0003-4819-150-3-200902030-00007 · Cited by 1,613
2017 Alzheimer's disease facts and figures
(, T. D. B. T. A.-R. C. C. A. S. O. A. C. B. S., different, ). J. A. I. A., destroyed, S. A. T. A. S. T. M. E. T. M. C. I. S. I. A. G. W. A. T. R. N. I. T. O. B. T. F. N. T. B. D. A. D. A. U. I. B. R. I. I. F. N. M. A. N. I. O. P. O. T. B. A. D. A., difficulties, I. E. O., agitation, I. N. S. S. A., & delusions., S. A. (2017) · Alzheimer s & Dementia · doi:10.1016/j.jalz.2017.02.001 · Cited by 1,366
Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial
Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2004.52202.x · Cited by 1,365
Comprehensive Discharge Planning for the Hospitalized Elderly
Naylor, M. D., Brooten, D., Jones, R., Lavizzo-Mourey, R., Mezey, M., & Pauly, M. V. (1994) · Annals of Internal Medicine · doi:10.7326/0003-4819-120-12-199406150-00005 · Cited by 730
Improving caregiver well-being delays nursing home placement of patients with Alzheimer disease
Mittelman, M. S., Haley, W. E., Clay, O. J., & Roth, D. L. (2006) · Neurology · doi:10.1212/01.wnl.0000242727.81172.91 · Cited by 602
Association of Incident Dementia With Hospitalizations
Phelan, E. A., Borson, S., Grothaus, L., Balch, S., & Larson, E. B. (2012) · JAMA · doi:10.1001/jama.2011.1964 · Cited by 547
End-of-Life Transitions among Nursing Home Residents with Cognitive Issues
Gozalo, P., Teno, J. M., Mitchell, S. L., Skinner, J., Bynum, J., Tyler, D., & Mor, V. (2011) · New England Journal of Medicine · doi:10.1056/nejmsa1100347 · Cited by 484
Revnic, C. R. S., Revnic, F. G., & Voinea, S. C. (2017) · Alzheimer s & Dementia · doi:10.1016/j.jalz.2017.06.033 · Cited by 370
Continuity of Care: The Transitional Care Model
Hirschman, K. B., Shaid, E., McCauley, K. M., Pauly, M. V., & Naylor, M. D. (2015) · OJIN The Online Journal of Issues in Nursing · doi:10.3912/ojin.vol20no03man01 · Cited by 292
Self-citationOuslander, J. G., Bonner, A., Herndon, L., & Shutes, J. (2014) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2013.12.005 · Cited by 282
Effect of the Goals of Care Intervention for Advanced Dementia: A Randomized Clinical Trial
Hanson, L. C., Zimmerman, S., Song, M.-K., Lin, F.-C., Rosemond, C., Carey, T. S., & Mitchell, S. L. (2017) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2016.7031 · Cited by 275
Spijker, A., Vernooij‐Dassen, M., Vasse, E., Adang, E., Wollersheim, H., Grol, R., & Verhey, F. (2008) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2008.01705.x · Cited by 223
Fick, D. M., Steis, M. R., Waller, J. L., & Inouye, S. K. (2013) · Journal of Hospital Medicine · doi:10.1002/jhm.2077 · Cited by 217
Interventions to Improve Transitional Care Between Nursing Homes and Hospitals: A Systematic Review
LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby‐Whitehead, J., & Hanson, L. C. (2010) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2010.02776.x · Cited by 189
Interventions to improve patient safety in transitional care – a review of the evidence
Laugaland, K., Aase, K., & Barach, P. (2012) · WORK: A Journal of Prevention, Assessment & Rehabilitation · doi:10.3233/wor-2012-0544-2915 · Cited by 184
High‐value transitional care: translation of research into practice
Naylor, M. D., Bowles, K. H., McCauley, K. M., Maccoy, M. C., Maislin, G., Pauly, M. V., & Krakauer, R. S. (2011) · Journal of Evaluation in Clinical Practice · doi:10.1111/j.1365-2753.2011.01659.x · Cited by 159
Patient Activation and 30-Day Post-Discharge Hospital Utilization
Mitchell, S. E., Gardiner, P. M., Sadikova, E., Martin, J. M., Jack, B. W., Hibbard, J. H., & Paasche‐Orlow, M. K. (2013) · Journal of General Internal Medicine · doi:10.1007/s11606-013-2647-2 · Cited by 158
Samus, Q. M., Johnston, D. M., Black, B. S., Hess, E., Lyman, C. H., Vavilikolanu, A., Pollutra, J., Leoutsakos, J., Gitlin, L. N., Rabins, P. V., et al. (2014) · American Journal of Geriatric Psychiatry · doi:10.1016/j.jagp.2013.12.175 · Cited by 156
Pimouguet, C., Lavaud, T., Dartigues, J.-F., & Helmer, C. (2010) · The journal of nutrition health & aging · doi:10.1007/s12603-010-0314-4 · Cited by 144
Lin, P., Fillit, H. M., Cohen, J. T., & Neumann, P. J. (2013) · Alzheimer's & Dementia · doi:10.1016/j.jalz.2012.11.002 · Cited by 142
Analysis of case management programs for patients with dementia: A systematic review
Somme, D., Trouvé, H., Dramé, M., Gagnon, D., Couturier, Y., & Saint‐Jean, O. (2012) · Alzheimer s & Dementia · doi:10.1016/j.jalz.2011.06.004 · Cited by 123
Ingber, M. J., Feng, Z., Khatutsky, G., Wang, J. M., Bercaw, L. E., Zheng, N. T., Vadnais, A., Coomer, N. M., & Segelman, M. (2017) · Health Affairs · doi:10.1377/hlthaff.2016.1310 · Cited by 120
Judge, K. S., Bass, D. M., Snow, A. L., WILSON, N. L., Morgan, R. O., Looman, W. J., McCarthy, C. A., & Kunik, M. E. (2011) · The Gerontologist · doi:10.1093/geront/gnq097 · Cited by 116
Transitions in Care in a Nationally Representative Sample of Older Americans with Dementia
Callahan, C. M., Tu, W., Unroe, K. T., LaMantia, M. A., Stump, T. E., & Clark, D. O. (2015) · Journal of the American Geriatrics Society · doi:10.1111/jgs.13540 · Cited by 107
Watkin, L., Blanchard, M. R., Tookman, A. J., & Sampson, E. L. (2011) · International Journal of Geriatric Psychiatry · doi:10.1002/gps.2693 · Cited by 107
THE PSYCHOLOGICAL SYMPTOMS OF CONJUGAL BEREAVEMENT IN ELDERLY MEN OVER THE FIRST 13 MONTHS
Byrne, G. J., & Raphael, B. (1997) · International Journal of Geriatric Psychiatry · doi:10.1002/(sici)1099-1166(199702)12:2 · Cited by 106
Naylor, M. D., Hirschman, K. B., Hanlon, A. L., Bowles, K. H., Bradway, C., McCauley, K. M., & Pauly, M. V. (2014) · Journal of Comparative Effectiveness Research · doi:10.2217/cer.14.14 · Cited by 91
Self-citationShankar, K. N., Hirschman, K. B., Hanlon, A. L., & Naylor, M. D. (2014) · Journal of the American Geriatrics Society · doi:10.1111/jgs.12657 · Cited by 85
Self-citationEffects of the NYU Caregiver Intervention-Adult Child on Residential Care Placement
Gaugler, J. E., Reese, M., & Mittelman, M. S. (2013) · The Gerontologist · doi:10.1093/geront/gns193 · Cited by 77
Dementia case management and risk of long‐term care placement: a systematic review and meta‐analysis
Tam‐Tham, H., Cepoiu‐Martin, M., Ronksley, P. E., Maxwell, C. J., & Hemmelgarn, B. R. (2012) · International Journal of Geriatric Psychiatry · doi:10.1002/gps.3906 · Cited by 74
Amjad, H., Wong, S. K., Roth, D. L., Huang, J., Willink, A., Black, B. S., Johnston, D. M., Rabins, P. V., Gitlin, L. N., Lyketsos, C. G., et al. (2017) · Health Services Research · doi:10.1111/1475-6773.12647 · Cited by 69
Project BOOST Implementation: Lessons Learned
Williams, M. V., Li, J., Hansen, L. O., Forth, V. E., Budnitz, T. L., Greenwald, J. L., Howell, E. E., Halasyamani, L. K., Vidyarthi, A. R., & Coleman, E. A. (2014) · Southern Medical Journal · doi:10.14423/smj.0000000000000140 · Cited by 68
Multi‐professional communication for older people in transitional care: a review of the literature
Allen, J., Ottmann, G., & Roberts, G. (2012) · International Journal of Older People Nursing · doi:10.1111/j.1748-3743.2012.00314.x · Cited by 68
A controlled trial of Partners in Dementia Care: veteran outcomes after six and twelve months
Bass, D. M., Judge, K. S., Snow, A. L., WILSON, N. L., Morgan, R. O., Maslow, K., Randazzo, R., Moye, J. A., Odenheimer, G. L., Archambault, E. G., et al. (2014) · Alzheimer s Research & Therapy · doi:10.1186/alzrt242 · Cited by 65
Kable, A., Chenoweth, L., Pond, D., & Hullick, C. (2015) · BMC Health Services Research · doi:10.1186/s12913-015-1227-z · Cited by 65
Translating Research Into Practice: Case Study Of A Community-Based Dementia Caregiver Intervention
Mittelman, M. S., & Bartels, S. J. (2014) · Health Affairs · doi:10.1377/hlthaff.2013.1334 · Cited by 64
Boltz, M., Chippendale, T., Resnick, B., & Galvin, J. E. (2015) · Alzheimer Disease & Associated Disorders · doi:10.1097/wad.0000000000000072 · Cited by 61
Respite care for people with dementia and their carers
Lee, H., & Cameron, M. H. (2004) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd004396.pub2 · Cited by 61
Gilmore-Bykovskyi, A. L., Roberts, T. J., King, B. J., Kennelty, K. A., & Kind, A. J. H. (2017) · The Gerontologist · doi:10.1093/geront/gnw085 · Cited by 56
Gitlin, L. N., & Wolff, J. (2011) · Annual Review of Gerontology and Geriatrics · doi:10.1891/0198-8794.31.31 · Cited by 55
Soo Borson, B., Boustani, M. A., Buckwalter, K. C., Burgio, L. D., Chodosh, J., Fortinsky, R. H., Gifford, D. R., Gwyther, L. P., Koren, M. J., Lynn, J., et al. (2016) · Alzheimer s & Dementia · doi:10.1016/j.jalz.2016.01.005 · Cited by 54
Chenoweth, L., Kable, A., & Pond, D. (2015) · Australasian Journal on Ageing · doi:10.1111/ajag.12205 · Cited by 53
Medicaid Home- and Community-Based Services: Impact of the Affordable Care Act
Harrington, C. A., Ng, T., LaPlante, M. P., & Kaye, H. S. (2012) · Journal of Aging & Social Policy · doi:10.1080/08959420.2012.659118 · Cited by 51
Bellantonio, S., Kenny, R. A., Fortinsky, R. H., Kleppinger, A., Robison, J. T., Gruman, C., Kulldorff, M., & Trella, P. M. (2008) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2007.01591.x · Cited by 50
Bass, D. M., Judge, K. S., Maslow, K., WILSON, N. L., Morgan, R. O., McCarthy, C. A., Looman, W. J., Snow, A. L., & Kunik, M. E. (2015) · Alzheimer s & Dementia Translational Research & Clinical Interventions · doi:10.1016/j.trci.2015.03.003 · Cited by 41
Hanson, L. C., Song, M., Zimmerman, S. I., Gilliam, R., Rosemond, C. A., Chisholm, L., & Lin, F. (2016) · Clinical Trials · doi:10.1177/1740774516650863 · Cited by 35
Systematic review of planned care transitions for persons with dementia
Ray, C. A., Ingram, V., & Cohen-Mansfield, J. (2015) · Neurodegenerative Disease Management · doi:10.2217/nmt.15.23 · Cited by 29
Meuleners, L. B., Fraser, M. L., Bulsara, M. K., Chow, K., & Ng, J. Q. (2016) · BMC Neurology · doi:10.1186/s12883-016-0711-3 · Cited by 29
Sloane, P. D., Schifeling, C. H., Beeber, A. S., Ward, K. T., Reed, D., Gwyther, L. P., Matchar, B., & Zimmerman, S. (2017) · Journal of the American Geriatrics Society · doi:10.1111/jgs.14672 · Cited by 27
Best Practices for Developing Specialty Nursing Scope and Standards of Practice.
Finnell, D., Thomas, E. L., Nehring, W., McLoughlin, K., & Bickford, C. J. (2015) · Online Journal of Issues in Nursing · doi:10.3912/ojin.vol20no02man01 · Cited by 16
Studying Nursing Interventions in Acutely Ill, Cognitively Impaired Older Adults
McCauley, K. M., Bradway, C. K., Hirschman, K. B., & Naylor, M. D. (2014) · AJN American Journal of Nursing · doi:10.1097/01.naj.0000454851.22018.5d · Cited by 13
Self-citationLin, P., Rane, P., Fillit, H. M., Cohen, J. T., & Neumann, P. J. (2016) · Alzheimer s & Dementia · doi:10.1016/j.jalz.2016.06.454 · Cited by 7
O2‐10‐06: A Common Allele in SPI1 Lowers Risk and Delays Age at Onset for Alzheimer's Disease
Huang, K., Jin, S. C., Harari, O., Kapoor, M., Bertelsen, S. E., Czajkowski, J., Lambert, J., Chouraki, V. A., Bellenguez, C., Grenier‐Boley, B., et al. (2016) · Alzheimer s & Dementia · doi:10.1016/j.jalz.2016.06.453 · Cited by 4
Research works printed but not linked: 3
- Alzheimer’s Association, 2017, Policy brief: Reducing potentially preventable hospitalizations for people living with Alzheimer’s and other dementias
- American Medical Directors Association (AMDA), 2010, Transitions of care in the long-term care continuum clinical practice guidelines, 1
- 2015, Training to serve people with dementia: Is our health care system ready? Paper 2: A review of dementia training standards across health care settings
Cited by
Sorted by citations
2024 Alzheimer's disease facts and figures
(2024) · Alzheimer's & Dementia · doi:10.1002/alz.13809 · Cited by 2,536
Alzheimer’s Association Dementia Care Practice Recommendations
Fazio, S., Pace, D. D., Maslow, K., Zimmerman, S. I., & Kallmyer, B. A. (2017) · The Gerontologist · doi:10.1093/geront/gnx182 · Cited by 233
Fakha, A., Groenvynck, L., de Boer, B., van Achterberg, T., Hamers, J. P. H., & Verbeek, H. (2021) · Implementation Science · doi:10.1186/s13012-021-01087-2 · Cited by 70
Dementia caregiving across Latin America and the Caribbean and brain health diplomacy
Ibáñez, A., Pina-Escudero, S. D., Possin, K. L., Quiroz, Y. T., Peres, F. A., Slachevsky, A., Sosa, A. L., Brucki, S. M. D., & Miller, B. L. (2021) · The Lancet Healthy Longevity · doi:10.1016/s2666-7568(21)00031-3 · Cited by 65
Emergency Department Care Transitions for Patients With Cognitive Impairment: A Scoping Review
Gettel, C. J., Falvey, J. R., Gifford, A., Hoang, L., Christensen, L., Hwang, U., Shah, M. N., Aggarawal, N. T., Allore, H. G., Aloysi, A. S., et al. (2022) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2022.01.076 · Cited by 65
Metadata
- Authors
- Hirschman, K. B., & Hodgson, N. A.
- Affiliations
- University of Pennsylvania (US)
- Corresponding author
- Hirschman, Karen B
- Venue
- The Gerontologist
- Publisher
- Oxford University Press (OUP)
- Published
- 2018-01-18
- Volume
- 58
- Issue
- suppl_1
- Pages
- S129-S140
- ISSN
- 0016-9013 (ISSN-L)
- 1758-5341
- OpenAlex
- W2790474892
- Cited by
- 129
- References
- 56
- Citations by year
- 2026: 5 · 2025: 12 · 2024: 25 · 2023: 16 · 2022: 21 · 2021: 24 · 2020: 18 · 2019: 3 · 2018: 3
- FWCI
- 1.83
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Gerontologist (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Alzheimer’s Association
- Topics
- Health Sciences › Nursing › Leadership and Management › Hospital Admissions and Outcomes
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Adolescent and Pediatric Healthcare
- Keywords
- dementia, care transitions, evidence-based interventions, caregivers, goals of care, multidisciplinary team, practice models, person-centred care
- MeSH terms
- Aged, Continuity of Patient Care, Dementia, Humans, Patient Transfer, Social Support, Quality Improvement
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review