School of Nursing (M.T., M.F.), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
Duke University Medical Center (E.O.), Duke HomeCare and Hospice, Durham, North Carolina, USA.
J Pain Symptom Manage. 2024 Nov;68(5):435-442. doi: 10.1016/j.jpainsymman.2024.07.026. Epub 2024 Jul 29.
People with late-stage Alzheimer's diseases and related dementias (ADRD) have high risk for postacute complications and readmission; however, minimal research describes hospital transitional care.
Within the context of the ongoing ADRD-PC clinical trial, the purpose of this study was to describe the content and quality of transitional care of people with ADRD.
Descriptive mixed methods using data from a retrospective chart review and interviews with palliative care social workers and a nurse providing transitional care in the ADRD-PC clinical trial.
Of 40 dyads of people with late-stage ADRD and their caregivers, palliative care plans were documented for 29 patients (73%); completed postdischarge calls in 72 hours were made for 39 (98%) caregivers and calls in 2 weeks were made for 33 (78%). The content of postdischarge care was promoting continuity, identifying resources, helping caregivers feel heard, troubleshooting problems, and providing grief support. Challenges during transitional care were limited time to engage caregivers in hospital-based palliative care, educate caregivers about palliative care plans, coordinate care after transfers to long term care, and the scarcity of community ADRD resources. Facilitators of high quality transitional care were continuity of staff who saw the patient or caregiver across hospital and postacute contacts, caregiver understanding of goals of care, written palliative care plans, and resources for postdischarge care.
Findings indicate high quality dementia-specific transitional care occurs when staff have resources, such as ADRD training and care planning template, to pull the hospital palliative care plan forward into the postdischarge destination, help families fit the plan to new circumstances, and manage strain and grief related to changes in health and function.
患有晚期阿尔茨海默病和相关痴呆症（ADRD）的患者发生急性后期并发症和再入院的风险较高；然而，很少有研究描述医院过渡性护理。
在正在进行的 ADRD-PC 临床试验中，本研究旨在描述 ADRD 患者过渡性护理的内容和质量。
采用回顾性图表审查和姑息治疗社会工作者以及在 ADRD-PC 临床试验中提供过渡性护理的护士访谈的描述性混合方法。
在 40 对患有晚期 ADRD 的患者及其护理人员中，有 29 名患者（73%）记录了姑息治疗计划；72 小时内完成了 39 名（98%）护理人员的出院后电话随访，2 周内完成了 33 名（78%）护理人员的电话随访。出院后护理的内容包括促进连续性、确定资源、帮助护理人员感到被倾听、解决问题以及提供悲伤支持。过渡性护理期间的挑战包括与护理人员在医院进行姑息治疗的时间有限、教育护理人员姑息治疗计划、协调向长期护理机构转移后的护理以及社区 ADRD 资源稀缺。高质量过渡性护理的促进因素包括跨医院和急性后期接触看到患者或护理人员的员工连续性、护理人员对护理目标的理解、姑息治疗计划的书面记录以及出院后护理的资源。
研究结果表明，当工作人员拥有资源（如 ADRD 培训和护理计划模板）将医院姑息治疗计划提前推进到出院目的地、帮助家庭根据新情况调整计划以及管理与健康和功能变化相关的压力和悲伤时，就会发生高质量的痴呆症特定过渡性护理。
