Unique Care Needs of People with Dementia and Their Caregivers during Transitions from Skilled Nursing Facilities to Home and Assisted Living: A Qualitative Study.
Mark Toles, Jennifer Leeman, Lisa Gwyther and 3 others
PMID 35926571WHAT IT FOUND
During skilled nursing facility to home transitions, families often did not recognize cognitive decline until after discharge.
They were then unprepared for symptoms, medications, pain, falls, daily tasks, and had little support for themselves.
Key findings
01Staff reported that many caregivers and patients were not ready to acknowledge cognitive decline or engage in dementia care planning, and home care nurses said recognition often happened after discharge.
02Caregivers reported little guidance for managing dementia symptoms at home, including medication resistance, pain, bathing and dressing, and falls shortly after returning home.
03Staff identified cost as a primary barrier to community supports, and caregiver support was described as an overlooked unmet need.
STILL TO COME
How it was doneWhat they foundWhat it means for OTsWhat it means for RNs
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What it does not show
Only 3 people with dementia were interviewed, while 10 caregivers were interviewed, so the patient voice was limited. The sample was small and came from four skilled nursing facilities in one organization in one state, so saturation may not have been reached. The people with dementia and caregivers were all reported as white, so findings may not apply across racial and ethnic groups. Staff were already experienced with a transitional care program, so their views may not represent staff in facilities without such experience. Dementia status relied on diagnosis or a score below 13 on a Brief Inventory for Mental Status test, which may misclassify some people. Caregiver transcripts from assisted living were included because themes were judged similar, so the findings are not only about discharge to home.
The easy way to misread this
Do not read these themes as evidence that a transitional care program works. The study described what staff, patients and caregivers said about unmet needs; it did not test an outcome.