ED-LEAD: Emergency Departments LEading the transformation of Alzheimer's and Dementia care

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PROJECT SUMMARY In persons living with dementia (PLWD), an Emergency Department (ED) visit is a critical event and an opportunity to address the unmet needs that preceded the visit. Our multiple PI (mPI) team have together conducted cluster-randomized, multi-site trials in >50 EDs as well as multiple hospice and home health agencies, and are uniquely poised to address previous shortcomings in the development of scalable models of care for PLWD. Through this work, and that of our co-investigators, we have developed and tested three interventions relevant to PLWD and their care partners who visit the ED: 1) emergency care redesign (UH3AT009844) of new and intentional workflows for emergency providers reinforced by digital alerts and structured collaboration between sites, already shown to increase identification of advance care plans and enlisted multidisciplinary support; 2) a nurse-led telephonic care program (PCORI) that increased advance care planning and connected patients to hospice; and 3) a community paramedic-led structured coaching intervention (R01AG050504) that reduced the odds of an ED revisit within 30 days by 75%. Building on this evidence, the overarching goal of EDs LEading the Transformation of Alzheimer’s and Dementia Care (ED- LEAD) is to turn an ED visit from a crisis into an opportunity to improve the well-being of PLWD and their care partners. ED-LEAD will be embedded in a diverse group of 14 health systems, including 80 EDs with substantial racial and ethnic diversity, with the ED as the unit of randomization. An Administrative Core will oversee completion of all administrative milestones including integrating expertise and guidance from two NIA- funded networks and an External Advisory Board. An Implementation Core will: 1) harmonize core functions and processes; 2) optimize clinical decision support; and 3) and enable intervention fidelity across the three interventions. Finally, a Statistical Analysis Core will provide biostatistical and data management support. Our specific aims are to: 1) optimize a concurrently run emergency care redesign, nurse-led telephonic care, and community paramedic-led transitions intervention in PLWD for feasibility, fidelity and usability in two EDs; 2) study the effectiveness of these three interventions, alone and in combination, for PLWD with serious illness in a cluster-randomized multifactorial trial embedded within 80 EDs on: ED revisits, hospitalizations, and healthy days at home following the index ED visit; and 3) determine site, provider, patient, and care partner-level characteristics within a diverse population associated with variation in implementation of each intervention. ED- LEAD will address shortcomings noted in the National Academies of Sciences, Engineering, and Medicine report on PLWD by providing high-quality, real-world evidence that may improve the lives and reduce suffering of PLWD and their care partners. It will address key strategic goals of NIA and the National Alzheimer’s Plan to “implement and evaluate new care models to support effective care transitions”, and provide health systems with the necessary evidence to scale interventions for this vulnerable population.