Understanding transitional care provided to older adults with and without dementia: A mixed methods study
Abstract
Introduction There are numerous effective transitional care interventions yet they are not routinely implemented. Furthermore, few interventions exist for older adults with dementia. A first step in developing effective interventions for dementia patients and increasing intervention uptake for all patients is to understand the current delivery process of transitional care. Methods A mixed methods study using an explanatory multiphase design was conducted. Guided by provider interviews, medical charts were reviewed to collect information on the day-to-day transitional care being delivered to older adults. Then providers were interviewed again to assess the accuracy of those results and provide context. Results The medical charts of 210 older adults (126 with dementia and 84 without) were reviewed and nine providers representing various professional roles including social work, nursing, and case management were interviewed. Social workers and case managers were primarily involved in discharge planning, communicating with providers outside the hospital, advanced care planning, providing social and community supports, and making follow-up appointments. Registered nurses were the primary providers of patient education and medication safety while physicians were primarily involved in ensuring that necessary information was available in the discharge summary and that it was available in the chart. Discussion This study found distinct patterns in the delivery of transitional care, including the unique roles nursing, social work, and case management have in the process. Furthermore, these patterns were found to differ between patients with and without dementia. These findings are both consistent and inconsistent with the existing literature on transitional care interventions.
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These challenges were particularly evident during discharge, prognostic discussions, and the management of neuropsychiatric symptoms.
“These challenges were particularly evident during discharge, prognostic discussions, and the management of neuropsychiatric symptoms (Parker et al., 2021; Prusaczyk et al., 2020; Radcliffe et al., 2023; Sawan et al., 2021).”
From Mind the gap: a systematic review of barriers, facilitators, and experiences of care transitions for people living with dementia and their informal caregivers. (2026) · cites this paper as Prusaczyk et al., 2020
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- Authors
- Prusaczyk, B., Fabbre, V., Morrow-Howell, N., & Proctor, E.
- Affiliations
- Washington University in St. Louis (US)
- Corresponding author
- Prusaczyk, Beth
- Venue
- International Journal of Care Coordination
- Publisher
- SAGE Publications
- Published
- 2020-03
- Volume
- 23
- Issue
- 1
- Pages
- 14-23
- ISSN
- 2040-4026 (ISSN-L)
- 2053-4345
- 2053-4353
- OpenAlex
- W3009908158
- Cited by
- 13
- References
- 34
- Citations by year
- 2026: 3 · 2025: 2 · 2024: 1 · 2023: 1 · 2022: 3 · 2021: 1 · 2020: 2
- FWCI
- 1.69
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- International Journal of Care Coordination (publishedVersion)
- Funders
- Council on Social Work Education
- National Association of Social Workers Foundation
- Topics
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Keywords
- care transitions, older adults, dementia, discharge planning, care coordination, social work, case management, registered nurses, advance care planning, patient education, drug safety, follow-up care
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