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

Abstract

Transitions between hospital and community are particularly challenging for vulnerable adults experiencing behavioural and psychological symptoms (BPSD) of dementia. Too often, miscommunication results in triggering a recurrence of disruptive behaviours leading to frustration of staff and families. As part of the implementation of Health Quality Ontario (HQO) Quality Standards, this project involved improving transitions using an electronic-based care plan on a 23-bed geriatric dementia unit in a mental health hospital. "My Dementia Careplan," is an interprofessional care plan that was developed in the electronic medical record (EMR) to enhance communication of information between healthcare providers when patients are being discharged to the community. It is written from the patient's perspective in collaboration with the family and interprofessional team. It describes strategies to manage behavioural challenges along with the standardized tools to objectively monitor progress. This care planning will help to support transition of knowledge between hospital and community.

Care Transtion in Hospital Discharge for Adult Patients: Integrative Literature Review

“…As strategies, the studies highlighted the post-discharge telephonecalls 21,26,[31][32][33][34][35][36][37][38] , home visits (HVs) [25][26]37 and also the association of HVs with telephone calls 20,26,[39][40][41] . Outpatient consultations 17,31,[42][43] , discharge with home care service (SAD) teams [44][45] and the increasing use of technology 34,[46][47] are other strategies that help discharge and continuity of care.…”

“…The use of technology to aid continuity of care in post-discharge was highlighted in three studies 34,[46][47] . One of them used big data technological innovation, which automatically alerts patient discharge via e-mail to the patient referral service 34 .…”

“…In another study, an interprofessional care plan was elaborated in the electronic medical records, specific for patients with dementia. The team involved in the care, both from the hospital and the community, should access and maintain it 46 . These two studies, with the help of technology, increased community monitoring and improved communication between health services, reducing gaps in transitions 34,46 .…”

“…The team involved in the care, both from the hospital and the community, should access and maintain it 46 . These two studies, with the help of technology, increased community monitoring and improved communication between health services, reducing gaps in transitions 34,46 .…”

Dementia: A Situation for Concern

“…The issue concludes with a discussion on using technology to assist with transitional care for persons living with dementia. According to Ritchie et al (2017) transitions between hospital and community are particularly challenging for vulnerable adults experiencing behavioural and psychological symptoms (BPSD) of dementia. Too often, miscommunication results in triggering a recurrence of disruptive behaviours leading to frustration of staff and families.…”