Mending the Cracks: A Case Study in Using Technology to Assist with Transitional Care for Persons with Dementia

Area of Science:

• Geriatric Medicine
• Psychiatry
• Health Informatics

Background:

• Hospital to community transitions are difficult for dementia patients with behavioral and psychological symptoms (BPSD).
• Miscommunication during transitions can trigger disruptive behaviors, causing distress for patients, families, and staff.
• Existing care transitions lack standardized methods for communicating BPSD management strategies.

Purpose of the Study:

• To improve the transition of care for vulnerable adults with dementia experiencing BPSD.
• To implement an electronic-based care plan to enhance interprofessional communication during discharge.
• To reduce the recurrence of disruptive behaviors and associated distress.

Main Methods:

• Development and implementation of an electronic interprofessional care plan, "My Dementia Careplan," within an electronic medical record (EMR) system.
• The care plan was created from the patient's perspective, involving families and the interprofessional team.
• Inclusion of strategies for managing behavioral challenges and standardized monitoring tools.

Main Results:

• The electronic care plan facilitated enhanced communication of patient information between hospital and community healthcare providers.
• Standardized tools enabled objective monitoring of patient progress and behavioral challenges.
• The project aimed to support knowledge transition, thereby improving care continuity.

Conclusions:

• Electronic care plans can significantly improve communication during hospital to community transitions for dementia patients with BPSD.
• "My Dementia Careplan" offers a structured approach to managing behavioral symptoms and supporting patients and families.
• This initiative aligns with Health Quality Ontario (HQO) Quality Standards for dementia care transitions.