Care Coordination & Transitions

Collaborate regarding the opportunities and available resources to improve care coordination and transitional care for people with dementia.

Recent Posts

Cognitive impairment often contributes to undesirable adverse clinical events such as de-conditioning, falls, malnutrition, and incontinence during hospitalizations and immediately following discharge.

I found a very interesting article from John Hopkins on Blood Pressure meds shown to decrease risk of Alzheimer's & one from HealthDay. Here are the two links:

What if there was a place you could call home that was in a self-contained world that had apartments, restaurants, cafes, supermarkets, gardens and your loved one with dementia would be safe?  Then you need to check out this place “The Amazing Village Designed Just For People With Dementia”

Over the past month, we've had the opportunity to engage with Duke A/GNP students and DNP students in our knowledge network.

Here's a link to a very interesting discussion.

Later I'll pull out some particularly useful resources that will help those of you who are interested in care coordination and management.


Below is a link to information on geriatric syndromes developed by the American Geriatrics Society that you may find helpful.  It includes a description of the following Geriatric Syndromes:

  • Bladder problems
  • Delirium
  • Dementia
  • Dizziness
  • Falls
  • Gait problems
  • Malnutrition & Swallowing problems
  • Osteoporosis
  • Pressure ulcers
  • Sensory Impairment
  • Sleep disorders

The material is written in language appropriate for family caregivers.

Advanced Practice Nurses (APNs) such as Nurse Practitioners and Clinical Nurse Specialists, are often key staff in evidence-based Care Models that improve transitions. Many are very similar to the VA program of coordinated care that Mary Blessing highlighted.  In the model that I reviewd, there is an APN that:

Hi Everyone, I am conducting a pilot study with the geriatric population where I work using an intervention that enhances mindfulness on overall well being.  The intervention is known as Heart Assisted Therapy-SR (HAT-SR).  HAT-SR is a non-invasive breathing technique that increases awareness and acceptance by centering on the heart.  Individuals place their hands on their heart, clear their mind, perform a breathing technique and repeat an acceptance statement (Diepold, 2006, Diepold, 2013).

When I went to visit my folks this summer my uncle was telling my dad he needed to take Coconut Oil.  My uncle is a retired doctor so my dad believes he should take Coconut Oil.  We also have a family history of Alzheimer’s.  My dad is 81 years young and still very sharp, but decided he should start Coconut Oil.  Then at work a patient asked me about Coconut Oil.  I realized a lot of my patient’s try alternative/complimentary medicine and that I needed to know more about coconut oil and other touted remedies for Alzheimer’s.


Look at the links below for information about the VA programs where Oreon and Kendra work.


I have also included links to two evidence-based approaches to care for older adults with dementia:

I continue to hear about Obamacare and how it will affect the elderly.  The information is scary “Obamacare is going to destroy the elderly,” ObamaCare cuts the hospitals will cost seniors their lives”  “Obama’s sneak attack on seniors” and the titles go on.  Even though I am not on Medicare, yet, the majority of my patients are, so I thought I better look into this. 


The US Preventive Services Task Force is an authoritative group that issues evidence-based recommendations for clinical care.

They have recently updated their statement on Screening for Dementia and Cognitive Impairment.

Their recommendation remains that there is insufficient evidence to recommend for or against screening.

The guidance statement is the result of a very careful evidence summary and public comment period.

It also includes a very well done patient education brochure.

Both are included in the links below.

I have recently been appointed to a National Advisory Group on development of a Uniform Curriculum on Alzheimer's Disease.

Part of the work involves reviewing an existing set of materials developed by a group in Minnesota called "Act on Alzheimer's"

Note that all of the materials can be used by anyone for free - -you just can't sell them!

Please consider reviewing some of these materials, and giving me your feedback on how you might use them in your own work.

What other content would you like to see developed?


Here is a link to a great article with a video on pallative care sent to me by the Director of the Wooten Laboratory at the Harriet and John Wooten Laboratory for Alzheimer's and Neurodegenerative Disease Research.

He uses this when talking to family members about the decision to place loved once with a  feeding tube.



The article Partners in Dementia Care; A Care Coordination Intervention for Individuals with Dementia and Their Family Caregiver, by Judge, Bass, Snow et. al (2011) describes a care coordination intervention called Partners in Dementia (PDC) that is for veterans with dementia and their caregivers.

The intervention involved a formal partnership between VA medical centers and local Alzheimer’s Association chapters (in Houston and Boston).

As Kathleen Morrow mentioned in her blog posting, people with dementia have numerous unmet needs.

Especially, I feel that there is not enough information for early stage dementia people.

Dementia is progressive disease: the abilities to remember, understand, and communicate gradually declines.

Understanding dementia, making a plan for self-care (living arrangement), and sharing emotional distress with others with early stage dementia may help early stage dementia people to cope more easily.

The link below offers information about transitions in care:

The Need for Better Coordination of Care

The Transition Record

Special Considerations for Discharge

Transitions in Care

I was asked the question again the other day:   When is it time to place a loved one with Alzheimer’s in a nursing home? I thought about a personal story that I want to share.