Emergency Care Redesign (ECR)

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PROJECT SUMMARY Persons living with dementia (PLWD) and their care partners visit the emergency department (ED) more frequently than those who are unaffected, and face unique and complex challenges associated with managing Alzheimer’s Disease and Alzheimer’s Disease Related Dementias (AD/ADRD) and presenting symptoms. Team-based dementia care has worked well for PLWD, and an emergency care redesign intervention (UH3AT009844) of new and intentional workflows for emergency providers reinforced by digital alerts has increased advance care plans and enlisted multidisciplinary support. The psychosocial challenges and the inherent complexity of AD/ADRD care beg for a way to simplify a feasible assessment and ensure adoption of an emergency care team-based strategy. Simplifying an approach to reflect a less time-intensive and more pragmatic intervention while attending to needed knowledge, sensitivities, and a structure to achieve best care for PLWD and their care partners (dyads) requires three core components: 1) identifying problems; 2) prioritizing problems (inclusive of goals of care); and 3) establishing feasible, psychosocially sensitive interventions. While these components are essential to reduce ED revisits and other outcomes of critical importance to dyads, such results are unlikely without an embedded structure and an informatic-supported workflow that emphasizes and encourages care processes congruent with high-quality emergency care. The proposed intervention, Emergency Care Redesign, will provide core components of trial-tested dementia care management programs, embedded within an educational structure for emergency care providers (nurses, physicians, nurse practitioners, physician assistants, and social workers), clinical decision supports for PLWD notification, reminders and instructional brief videos for reinforcement, a shared structured worksheet in the electronic health record for critically needed assessments and data acquisition, audit and feedback supporting a biweekly case-review consultation, and a post visit social work phone call to reinforce community referrals for all PLWD who visit the ED. We will optimize, within one ED, this dementia-informed redesigned acute care (Emergency Care Redesign) and then implement this program in 40 out of 80 EDs within 14 health systems throughout the United States. We will test the effectiveness of emergency care redesign-informed procedures for the care of PLWD and care partners either as a single intervention or in combination with nurse-led telephonic care and/or a community paramedic-led transitions intervention in a cluster-randomized, multifactorial trial (in these 40 facilities) on the following outcomes: ED revisits within 30 days following the index visit, hospitalizations, and healthy days at home within 6 months of ED discharge. We will determine site, provider, patient, and care partner-level characteristics associated with fidelity of implementation and variation in impact of ED dementia-informed care. This intervention promises to reduce ED revisits while providing evidence-based, real-world care to improve the lives of PLWD with serious illness and their care partners.