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Nurse-Led Telephonic Care Following Emergency Department Visits for Persons Living With Dementia and Their Care
Valerie T Cotter1,2, Corita R Grudzen3, Janessa Griffith3
1Johns Hopkins, School of Nursing, Baltimore, Maryland, USA.
Journal of the American Geriatrics Society
|May 21, 2026
Summary
Preventable emergency department visits by persons living with dementia (PLWD) can be reduced. A new longitudinal nurse-led telephonic care (NLTC) program aims to support PLWD and their care partners, improving quality of life.
Area of Science:
- Gerontology
- Dementia Care
- Health Services Research
Background:
- Millions of persons living with dementia (PLWD) in the US rely on care partners who often lack adequate community support.
- Care partner challenges frequently lead to preventable emergency department (ED) visits for PLWD, a suboptimal and potentially traumatic experience.
- Existing healthcare systems struggle to provide timely clinical access for common dementia-related needs in the community.
Purpose of the Study:
- To describe the development of a longitudinal nurse-led telephonic care (NLTC) program.
- To support care partners and persons living with dementia (PLWD) after an ED visit and community discharge.
- To evaluate the potential of NLTC to reduce ED utilization and improve care quality within the ED-LEAD trial.
Main Methods:
- Development of an NLTC program integrating components from Aliviado Dementia Care and EMPallA programs.
- Implementation within the Emergency Departments LEading Transformation of Alzheimer's and Dementia Care (ED-LEAD) trial.
- A factorially designed, embedded pragmatic clinical trial across 79 emergency departments.
Main Results:
- The NLTC program is being developed and implemented as part of a large-scale pragmatic clinical trial.
- The program aims to provide high-quality, person-centered support to PLWD and their care partners post-discharge.
- Successful implementation may demonstrate the effectiveness of NLTC in supporting community-dwelling PLWD.
Conclusions:
- Longitudinal nurse-led telephonic care (NLTC) offers a promising model for supporting persons living with dementia (PLWD) and their care partners.
- This approach has the potential to reduce preventable emergency department visits and improve overall quality of care and life.
- Widespread adoption of NLTC programs by health systems could significantly enhance dementia care delivery.
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