Background: Hospital admissions are stressful for adults with dementia and their caregivers. During care transitions from hospital to home, outcomes for adults with dementia depend, in part, on the caregiver’s health and well-being. We aimed to identify the resources and training needs of dementia caregivers during care transitions.
Methods: We conducted semi-structured interviews with licensed health professionals. Eligible health professionals provided care for Veterans with Alzheimer’s Disease and Related Dementias (ADRD) at the Michael E. DeBakey Veterans Affairs (VA) Medical Center in Houston, TX. Interviews were recorded and transcribed verbatim. We conducted a rapid qualitative analysis with structured summaries and matrices.
Results: Fifteen health professionals completed a semi-structured interview (4 Social Workers, 4 Hospitalists, 2 Inpatient Nurse Case Managers, 2 Geriatrics Providers, 1 Primary Care Provider, and 2 Geriatric Psychiatrists). Hospital admissions were seen as an opportunity to engage dementia caregivers to identify and arrange home services and supports. Health professionals reported that caregiver’s lack of knowledge regarding the availability of and Veteran’s eligibility for VA and community services and supports was a barrier to receiving needed help following discharge. Services and supports that include an “in-person” visit to provide an “extra pair of hands,” such as homemaker and home health aides, or that provide caregivers respite, such as adult day care, were felt to be important for caregivers following discharge. Opportunities to improve care transitions for caregivers included educating caregivers on the anticipated progression for dementia; offering training on how to manage behavioral disturbances before discharge; increasing referrals to caregiver support programs, home-based primary care, and respite care; and providing information on community resources. Across professions, interviewees recommended a dementia “navigator for the caregivers” who would meet the caregiver in the hospital and follow up with the caregiver after discharge to assist with post-discharge problem-solving, provide dementia-specific education, and connect the caregiver to VA and non-VA services and supports.
Conclusions: Health professionals identified opportunities to improve the hospital and care transition experience for caregivers of hospitalized veterans with dementia. Adding a dementia caregiver navigator who can follow the caregiver from the hospital to home was recommended across health professions and is supported by evidence-based practices that support dementia caregivers in outpatient and community settings.