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Enhancing Care Coordination:

Hospital to Home for Cognitively Impaired Older Adults and Their Caregivers

Name of study Enhancing Care Coordination: Hospital to Home for Cognitively Impaired Older Adults and Their Caregivers
Principal investigator Mary D. Naylor, PhD, RN, FAAN
Sponsor of study NIA & Marian S. Ware Alzheimer Program
Purpose of study and type of intervention To compare across three hospital sites the effects on health and cost outcomes observed by the following three interventions, each designed to enhance adaptation and improve outcomes of hospitalized cognitively impaired (CI) elders and their caregivers:
  1. Augmented Standard Care (ASC);
  2. Resource Nurse Care (RNC);
  3. Advanced Practice Nurse Care (APNC).
In Phase I of the study, each hospital site will have a different intervention. In Phase II of the study, each site will have the APNC intervention.
Inclusion criteria
  • Must reside within 30 miles of admitting hospital site (in Pennsylvania)
  • Age 65 and older
  • Speaks English
  • Admitted from home to one of three hospital sites
  • A documented history of pre-existing dementia in their medical records or pre-screen positive for cognitive impairment using our Pre-Screen Process
  • A primary caregiver (knowledgeable informant), defined as the spouse, family member, partner or friend, who will provide support following discharge to home and is reachable by telephone.
Exclusion criteria
  • End-Stage diseases (less than 6 months to live)
  • Primary diagnoses of cancer that are currently receiving treatment
Length of study April 2006 to August 2010
Placebo controlled? If so, open label extension available? N/A
Potential risks to participants Becoming tired or fatigued during interview. To alleviate this, interviewees can take a break, reschedule the visit, or withdraw from study.
Special features? (e.g., lumbar puncture) Each intervention offers something different:
  1. ASC - standard hospital and, if referred, home care plus early identification of CI during the patients’ hospitalization by trained registered nurses (RNs) with immediate feedback to patients’ primary nurses, attending physicians and discharge planners;

  2. RNC– standard hospital and, if referred, home care plus early identification of CI during the patient’s hospitalization by trained RNs and hospital care by RNs trained in the use of expert clinical guidelines developed to enhance the care management of hospitalized cognitively impaired elders and to facilitate their transition from hospital to home; or,

  3. APNC – standard hospital care plus transitional (hospital to home) care substituting for standard home care and provided by APNs with advanced training in the management of CI patients using an evidence-based protocol designed specifically for this patient group and their caregivers.

Phase II of the study (APNC) will begin rolling out in March 2008 at all sites.
Contact person & method for volunteering to participate Project manager/Co-Investigator:
Karen B Hirschman, PhD (215) 573-3755 hirschk@nursing.upenn.edu

Principal Investigator:
Mary D Naylor, PhD (215) 898-6088 naylor@nursing.upenn.edu
Link to study on PDtrials.org or Clinicaltrials.gov Click here to open the link in a new window.