Enhancing Care Coordination: Hospital to Home for Cognitively Impaired Older Adults and Their Caregivers

• Patient - Function [ Time Frame: At hospital admission and at 2-, 6-, 12-, and 26-weeks post-discharge ] [ Designated as safety issue: No ]
  Basic Activities of Daily Living
  
  
• Caregiver - Burden [ Time Frame: At hospital admission and at 2-, 6-, 12-, and 26-weeks post-discharge ] [ Designated as safety issue: No ]
  
• Patient - Health Care Costs [ Time Frame: Through 6 months ] [ Designated as safety issue: No ]
  
• Patient - Time to first rehospitalization or death; total rehospitalization days [ Time Frame: From index hospital discharge through 6 months ] [ Designated as safety issue: No ]
  Time calculated from index hospital discharge to first rehospitalization or death. Total days rehospitalized through six months.
  
  

• Patient - Total rehospitalizations [ Time Frame: From index hospital discharge through 6 months ] [ Designated as safety issue: No ]
  
• Patient - Cognitive Function [ Time Frame: At hospital admission and at 2-, 6-, 12-, and 26-weeks post-discharge ] [ Designated as safety issue: No ]
  
• Patient - Care Management [ Time Frame: From enrollment through 6 months ] [ Designated as safety issue: No ]
  
• Patient - Symptoms (Physical and depressive symptoms) [ Time Frame: At hospital admission and at 2-, 6-, 12-, and 26-weeks post-discharge ] [ Designated as safety issue: No ]
  
• Patient - Neuropsychiatric Behaviors [ Time Frame: At hospital admission and at 2-, 6-, 12-, and 26-weeks post-discharge ] [ Designated as safety issue: No ]
  
• Patient - Quality of Life [ Time Frame: At hospital admission and at 2-, 6-, 12-, and 26-weeks post-discharge ] [ Designated as safety issue: No ]
  
• Patient/Caregiver - Satisfaction with care [ Time Frame: At 2-weeks and post APNC intervention ] [ Designated as safety issue: No ]
  
• Caregiver - Depressive Symptoms [ Time Frame: At hospital admission and at 2-, 6-, 12-, and 26-weeks post-discharge ] [ Designated as safety issue: No ]
  

Cognitive impairment (CI) is a major health problem complicating the care of increasing numbers of older adults hospitalized for an acute medical or surgical condition. Dementia and delirium, the most common causes of CI among these elders, is associated with higher mortality rates, increased morbidity and higher health care costs. A growing body of science suggests that these patients and their caregivers are particularly vulnerable to systems of care that either do not recognize or ignore their needs. The consequences are devastating for the patients and their caregivers and add tremendous burden to hospital staffs coping with a severe shortage of nurses. For these reasons, the Institute of Medicine identified improved care management of this patient group as a national priority for action. Unfortunately, little evidence is available to guide optimal care of this patient group or to address the unique needs of their caregivers. Collectively, available evidence suggests that these patients may benefit from interventions aimed at improving management of CI, comorbid conditions or both but the exact nature and intensity of intervention needed to effectively and efficiently improve their outcomes and those of their caregivers is not known. Thus, the timing is excellent for rigorous research aimed at identifying care management strategies that will result in high quality, cost-effective outcomes for this challenging patient group and their caregivers.