Implementation of a Telehealth Palliative Care Model for Persons With Dementia

Implementation of a Telehealth Palliative Care Model for Persons With Dementia

Grounded in the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) Model, this study will assess the implementation outcomes of the Nurse Practitioner (NP) delivered telehealth Palliative Care Consultation in Post-Acute Care (PCC-PAC) intervention for persons living with dementia (PLWD) and their care-partners newly admitted to nursing homes (NHs) for post-acute care.

This single arm embedded pragmatic pilot clinical trial will provide data to assess the implementation outcomes of the Nurse Practitioner (NP) delivered telehealth Palliative Care Consultation in Post-Acute Care (PCC-PAC) intervention among 30 persons living with dementia (PLWD) and their care-partners newly admitted to one nursing homes (NH) for post-acute care.

Inclusion Criteria:

Stakeholders:

• (1) PC provider
• (2) Social Work (SW) NH champions
• (3) post-acute care unit nursing staff and providers (including medical directors)
• (4) NH leadership, information technology staff
• (5) PLWD and their care partner(s).

Person Living with Dementia (PLWD)

• documented dementia diagnosis
• admitted for post-acute care
• age ≥ 60 years
• if unable to participate in a conversation or lacking capacity to make healthcare decisions as determined by the NH staff/providers, a care partner who can act as a surrogate decision maker in the PCC-PAC.

Exclusion Criteria:

Stakeholders:

-PLWD who receives the intervention

PLWD:

• planned discharge within 48 hours of screening
• currently receiving hospice care