Five Tips to Help Ease Care Transitions for People With Dementia

About Juliet Holt Klinger

Senior Director of Dementia Care

Juliet is a passionate advocate for people living with dementia and their families. She is deeply committed to improving the cultural acceptance of those with cognitive differences. As our gerontologist and Senior Director of Dementia Care, Juliet develops person-centered care and programming for Brookdale’s dementia care communities. But if you ask her, Juliet says she continues to learn every day from the true experts, those living with dementia and their care partners. Juliet believes we need to move beyond the concept of caregiving, which implies a one-sided relationship, and embrace the idea of care partnering. Care partnering is about relationships built on cooperation—a two-way street promoting person-centered care and mutual feelings of purpose, where the person living with dementia also plays a strong role in shaping their care and daily routine. We are here to partner, learn and grow with our residents and families to make aging a better experience. After volunteering in nursing homes in high school, Juliet knew she wanted to work with older adults. While working on her bachelor’s degree in social work at the University of Iowa, she completed an Aging Studies Certificate program, before there were formal gerontology programs available. At Iowa, Juliet also had the chance to study with pioneers in the field of dementia care, an opportunity that shaped her passion for caring for those living with dementia. Trained as a gerontologist, with a master’s degree from the University of Northern Colorado, Juliet joined Brookdale in 2004. She is a seasoned senior living executive with more than 30 years of experience designing and executing innovative Alzheimer's and dementia care programs and living environments in both assisted living and skilled settings.

brookdale memory care resident and associate

Years ago, I met a resident named Juanita who was living with dementia and diabetes. Her deteriorating physical health led to several hospitalizations. Each time, she came back to my dementia care community, she was more frail and her dementia had worsened. Moving from the community to an unfamiliar setting like the hospital, and back again was taking its toll on Juanita and her family.

Unfortunately, Juanita’s story is quite common. The Alzheimer’s Association reports that people living with dementia are more likely to have other chronic conditions, such as heart disease, diabetes and kidney disease. They are also more likely to experience potentially avoidable hospitalizations for their chronic conditions. Older people living with dementia have nearly twice as many hospital stays per year as other older people.

To help improve care transitions and outcomes for people living with dementia like Juanita, the Alzheimer’s Association released guidelines in 2018: Dementia Care Practice Recommendations. Developed by 27 dementia care experts and based on a comprehensive review of current evidence, best practice, and expert opinion, the guidelines include recommendations that help define quality care across all care settings and throughout the disease course. The guidelines are intended for professional care providers who work with individuals living with dementia and their families in long-term and community-based care settings. Still, families can also use these recommendations to continue to advocate for and help improve person-centered care during transitions.

Transitions in care for persons living with dementia include “movement across settings and between providers increasing the risk for fragmented care and experiencing poor outcomes such as hospital-acquired complications and excess health care expenditures,” according to the Alzheimer’s Association report.

Here are examples of common transitions for a person living with dementia:

From home to a hospital or skilled nursing facility
From home to an emergency department
From an emergency department to an intensive care unit
From one team of clinicians or care providers to another

Tips for Easing the Transition

Because people living with dementia are at a greater risk for complications and breakdowns in care, the Alzheimer’s Association makes five specific recommendations to help make coordination of services and care transitions easier for people living with dementia before, during and after care transitions:

Ask questions. Your care provider should help prepare and educate you and your family about typical transitions in care. Communication should take place before, during and after transitions. Care providers should take the time to answer your questions, clarify each care setting, and explain different options to help give you peace of mind.
Stay in the loop. Expect timely and open communication of information between, across and within settings. Often, people are transferred to and from clinical settings without essential information. Make sure your care team is sharing medical information to make transitions more manageable and to avoid issues like unnecessary emergency department visits and medication errors.
Continue to participate and share your treatment preferences and goals. After any hospitalization or other significant change requiring a transition in care or level of care, your healthcare team should review and reassess your treatment preferences, advance directives and include an assessment of safety, health needs, and your caregiver’s ability to manage your needs.
Surround yourself with a strong collaborative care team to assist you and your family with transitions. Your team should be comfortable addressing the unique challenges for individuals living with dementia and other complex chronic conditions, as well as the needs of your family.
Encourage your care team to use evidence-based models to plan care transitions. The seven evidence-based models of care in the Dementia Care Practice Recommendations have been shown to help avoid unnecessary transitions. These models focus on preventing unnecessary transitions such as hospitalizations or emergency department visits and supporting placement in residential care settings such as nursing homes or assisted living communities, as needed.

How do you put these tips to work?

One of the most valuable tools you can use to apply the recommendations from the Alzheimer’s Association is a thoughtful and up-to-date transition plan. This plan is especially important if the person living with dementia has a lower stress threshold or is very attached to the presence of a particular caregiver or family member. A good transition plan can make adjustments to new settings more comfortable, and it should include specific person-centered information about regular routines and comfort levels with tasks like dining, bathing, need for privacy and comfort with touch and affection.

The transition plan should also meet the person living with dementia at their point of need, needs that will vary depending on their level of dementia. Most importantly, you and your family should stay involved and engaged. Having a family member close by during transitions will offer reassurance, comfort and consistency. At Brookdale, we value the relationships and partnerships we build with our residents living with dementia and their families. As part of your care team, we can help improve the coordination of services and care transitions with our person-centered approach and the application of evidence-based care models.