Identifying Patient, Care Partner, and Clinician Needs for Functional Recovery Following Hospitalization When...

Area of Science:

• Gerontology
• Health Services Research
• Dementia Care

Background:

• Hospitalization threatens home recovery for veterans with dementia.
• Current post-acute care often defaults to nursing homes, not home-based models.
• Veterans with dementia require tailored post-acute care for successful home reintegration.

Purpose of the Study:

• Identify needs for home-based post-acute care models for veterans with dementia.
• Inform implementation and adaptation of these models.
• Enhance recovery and quality of life for veterans with dementia.

Main Methods:

• Qualitative study using semi-structured interviews.
• Participants: 11 veterans with dementia, 13 care partners, 23 rehabilitation clinicians.
• Analysis guided by the Practical, Robust Implementation and Sustainability Model (PRISM).

Main Results:

• Collaborative decision-making and planning are essential for high-quality care.
• Effective follow-through ensures needs are met during hospital-to-home transitions.
• Alternative care options, including technology, are vital for optimizing care transitions.

Conclusions:

• Home-based post-acute care models can improve patient and family-centered outcomes.
• Evidence-based models are needed for effective, safe, and feasible post-acute care.
• Future research should focus on collaborative adaptation and development of these models.