Optimizing Transitions for Dual-Use Veterans Living with Dementia followingHospitalization in the Community

Background: The Veterans Health Administration (VA) mandated expanded community care services for
Veterans with the VA Maintaining Systems & Strengthening Integrated outside Networks (MISSION) Act of
2018. As a result, the VA has increasingly partnered with community-based facilities and growing number of
Veterans Living with Dementia (VLWD) will receive community and VA care (dual-users). However, there are
gaps in care for dual-use Veterans, including increased hospitalization and fragmented care.
Significance/Impact:
Understanding community care for dual-use Veteran health outcomes, care quality, and
safety is crucial and provides objective measures of MISSION Act. My CDA is significant for its potential to
uncover current transitional care gaps, while creating an adaptable, pragmatic intervention aimed at reducing
adverse outcomes for VLWD.
Innovation:
My CDA uses mixed methods to inform the identification of adverse transitional outcomes among
VLWD and the adaptation of a pilot intervention.
The VA is undergoing a major transformation due to the
MISSION Act. My CDA research is innovative in assessing community care for VLWD, is the first to assess
outcomes for VLWD in the MISSION Act era and inform adapted pilot intervention. The methods developed
and applied in this CDA will provide a roadmap for evaluating and comparing outcomes across care settings
while also identifying barriers and facilitators to transitions in care.
Specific Aims
Aim 1: Understand health care utilization patterns and associated outcomes of dual-use VLWD.
Aim 2: Understand preferences and transitional care needs of dual-use VLWD, their care partners, and
clinicians through qualitative interviews.
Aim 3: Adapt and pilot test an evidence-based transitional care model to improve transitional care outcomes
for VLWD following ED visit and/or hospitalization.
This work has the support of the VA
offices of Geriatrics and Extended Care, community care and emergency
medicine and
aligns with VA priority-- research focused on national legislative priorities affecting Veteran care,
notably the MISSION Act.
Methodology: We will use a mixed methods sequential quantitative-to-qualitative design. First, we will perform
a quantitative study of dual-use VLWD to understand factors that contribute to adverse outcomes (30-day re-
hospitalizations, 30-day ED readmissions and mortality within 30 days of hospital discharge). Second, we will
perform a qualitative study of dual-use VLWD (n = 25), their family caregivers (n = 25) and their clinicians (n =
25) to identify transitional care priorities and needs. Third, we will use findings from Aims 1 and 2 to adapt and
pilot an intervention aimed at reducing adverse outcomes of VLWD. Using mixed-methods, we will test the
feasibility and acceptability of the intervention.
Next steps: This CDA findings will be the basis for future work to study the effectiveness and impact on
Veteran outcomes.

Grant Number: 5IK2HX003341-03
NIH Institute/Center: VA
Principal Investigator: Roman Ayele