Transitions in Care for Older Nursing Home Residents with Dementia from Entry to Death: a retrospective cohort study, 2014-2019

Transitions in Care for Older Nursing Home Residents with Alzheimer?s disease and Alzheimer?s disease-related dementias from Entry to Death: a retrospective cohort study, 2014-2019 1 R03 AG070810-01 Project Summary/Abstract Care transitions are very common among nursing home (NH) residents with Alzheimer?s disease and Alzheimer?s disease-related dementias (AD/ADRD) and many of these are deemed avoidable.

Multiple hospitalizations at any point during NH stays, and particularly at the end of life, would be markers of poor care, diminished quality of life, and inefficient use of resources.

There is an urgent need to identify individuals with AD/ADRD who are at highest risk of harmful care transitions, identify care deficiencies that contribute to these transitions, and develop interventions that can be targeted to individuals with greatest risk.

Prior research provides some understanding of transition patterns older adults experience; however, there are several gaps: (a) transition studies among residents with AD/ADRD have not considered dementia severity or the relationship between AD/ADRD and co-morbidities; (b) the majority of research efforts have focused on singular care transitions in cross-sectional studies; (c) research has tended to emphasize the number of transitions without considering the length of stay in each setting; (d) most studies have not tracked changes in health over time, and no studies to our knowledge have applied mixture growth models to identify care trajectories for individuals with AD/ADRD; and (e) few studies have attempted to link quality of care with likelihood of care transitions or transition patterns over time.

In this proposed study, we will address these gaps and model care transitions between NH, hospital, emergency department, community, and death for a cohort of NH dual-eligible (Medicaid and Medicare) residents aged 65+ with AD/ADRD.

The study cohort will consist of approximately 8,500 residents who received NH care in Minnesota beginning in 2014 and followed for up to 5-years through 2019, to pursue three specific aims: 1) identify the main care trajectories in a cohort from entry to death (or censoring), 2) determine the impact of dementia severity and co-morbidities in influencing the patterns of care trajectories, and 3) examine the associations between markers of quality in NH care (general and end-of-life quality measures) and the most common trajectories.

This study is innovative in: 1) identifying key characteristics of high-risk groups with AD/ADRD in care transitions for intervention; 2) a more-complete understanding of patterns and determinants of care transitions among older adults with various levels of dementia; 3) analyzing the relationship between AD/ADRD and co-morbidities; 4) comparing the similarities and differences in care transitions between short- and long-stay residents with AD/ADRD; and 5) investigating whether residents with AD/ADRD living in NH with poor quality performance would experience more acute care transitions compared with those in facilities with better quality performance.

The longitudinal design of this proposed study will provide direction to policy and practice to permit evidence-based decision-making regarding optimal movement during an episode of dementia care.