The goal of the project is to conduct a prospective, randomized-controlled clinical trial to determine the extent to which the Coordinated-Transitional Care (C-TraC) program impacts transitional care quality, patient cognition/function, caregiver stress and 30-day rehospitalizations in patients with documented diagnoses of dementia discharged from the hospital to the community.

Patients with dementia often experience poor quality transitions from the hospital to the community. In response, the investigators developed and piloted the Coordinated-Transitional Care (C-TraC) program--a low-cost, telephone-based intervention designed to improve care coordination and outcomes in hospitalized patients with dementia or other high-risk conditions discharged to community settings.

A single-blind, prospective, randomized-controlled trial will be used with participants being randomly assigned to receive usual (i.e. standard) care, or usual care plus the C-TraC intervention. Outcomes will be assessed via scheduled phone-calls at 14, 30, and 90 days post-hospitalization. A 45-day phone call will also be conducted to complete a brief satisfaction survey with the caregiver about their post-hospital experience.

Patient Inclusion Criteria:

• English-speaking
• Have a working telephone
• Hospitalized on medical inpatient wards at UWHC
• A documented pre-hospitalization diagnosis of dementia.
• Alzheimer's Disease Cooperative Study - Clinical Dementia Rating (ADCS-CDR) score of > 0
• Have a family member/informal caregiver who has regular contact with them in the community setting

Caregiver Inclusion Criteria:

• English-speaking
• Have a working telephone
• Have contact with patient a minimum of once per week

Patient Exclusion Criteria:

• Discharged to institutional settings
• No identified caregiver
• Discharged to hospice
• Followed by complex case management or any form of intensive case management (e.g. transplant, congestive heart failure, dialysis)
• Score moderate-high on modified ASSIST tool for alcohol