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

Gustavson, Hudson, Wisdom, Woodward-Abel, Hoffman, Miller, Fink, Gaugler, Hagedorn. Identifying Patient, Care Partner, and Clinician Needs for Functional Recovery Following Hospitalization When Dementia is Present. Journal of The American Medical Directors Association. 2025 May 1; 26(5):105534, DOI: 10.1016/j.jamda.2025.105534.

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Abstract:

OBJECTIVES: Persons with dementia are frequently hospitalized, which threatens their ability to return to and live at home. Current post-acute paradigms tend to default to short-term rehabilitation in a nursing home. Still, alternative post-acute care models are crucial for veterans with dementia to recover at home. This study aims to identify the needs of veterans with dementia, care partners, and rehabilitation clinicians in relation to home-based models of care to inform the implementation and adaptation of models to the post-acute context. DESIGN: Qualitative study. SETTING AND PARTICIPANTS: Participants included veterans with dementia with recent history of hospitalization, care partners, and rehabilitation clinicians. METHODS: Semi-structured interviews were conducted across 3 groups (veterans with dementia, care partners, and rehabilitation clinicians) and analyzed using a rapid qualitative approach guided by the Practical, Robust Implementation and Sustainability Model (PRISM). RESULTS: Participants included 11 veterans with dementia, 13 care partners, and 23 rehabilitation clinicians. We identified 3 themes from the interviews: (1) collaborative decision making and planning are crucial to high-quality care, (2) follow-through is necessary to ensure needs are met when transitioning from hospital to home, and (3) alternative care options, including technology use, are important when optimizing transitions of care. CONCLUSION AND IMPLICATIONS: Alternative options for home care after hospital discharge may enhance patient-and family-centered outcomes. Future research must identify evidence-based models that can be collaboratively adapted or developed to provide effective, safe, and feasible post-acute care to optimize independence in the home and quality of life.