Nurse‐Led Telephonic Care Following Emergency Department Visits for Persons Living With Dementia and Their Care Partners: A Program Description
Open Access
- 21 May 2026
- journal article
- Published by Wiley in Journal of the American Geriatrics Society
Abstract
Most visits to the emergency department (ED) by persons living with dementia (PLWD) who are then discharged back into the community are preventable. However, care partners and other caregivers of the over 6 million PLWD residing in the United States lack the supports, services and timely access to clinical care to address many common needs in the community. Thus, care partners resort to taking the PLWD to the ED, a sub‐optimal environment that can be traumatic to the PLWD, increase iatrogenesis, and ultimately may not resolve the underlying reason for the visit. Longitudinal nurse‐led telephonic care (NLTC) provided following an ED visit with community discharge may present an effective and efficient model for health systems to support care partners, decant busy EDs, and provide high‐quality, person and family‐centered impactful care to support PLWD and their care partners. This paper describes the development of an NLTC program being implemented as part of the Emergency Departments LEading Transformation of Alzheimer's and Dementia Care (ED‐LEAD) trial, a factorially designed embedded pragmatic clinical trial in 79 EDs. The NLTC program utilizes components of two previously tested programs, the Aliviado Dementia Care quality improvement program, and the Emergency Medicine Palliative Care Access (EMPallA) nurse‐led telephonic palliative and transitional care program to support PLWD and their care partners. Successful implementation of the NLTC program may lead to increased uptake of NLTC programs by health systems, improving quality of care and quality of life for PLWD and their care partners.Keywords
Funding Information
- National Institute on Aging (U19 AG078105‐01A1)
- National Cancer Institute (P30 CA008748)
This publication has 31 references indexed in Scilit:
- A Bayesian Multi‐Factorial Design and Analysis for Estimating Combined Effects of Multiple Interventions in a Pragmatic Clinical Trial to Improve Dementia CareStatistics in Medicine, 2025
- Emergency department care transition barriers: A qualitative study of care partners of older adults with cognitive impairmentAlzheimer's & Dementia: Translational Research & Clinical Interventions, 2022
- Care transitions intervention reduces ED revisits in cognitively impaired patientsAlzheimer's & Dementia: Translational Research & Clinical Interventions, 2022
- Incorporating social determinants of health into comprehensive medication management: Insights from the fieldJACCP: Journal of the American College of Clinical Pharmacy, 2020
- Protocol for an embedded pragmatic clinical trial to test the effectiveness of Aliviado Dementia Care in improving quality of life for persons living with dementia and their informal caregiversContemporary Clinical Trials, 2020
- The Area Deprivation Index: A novel tool for harmonizable risk assessment in Alzheimer's disease researchAlzheimer's & Dementia: Translational Research & Clinical Interventions, 2020
- Effect of Collaborative Dementia Care via Telephone and Internet on Quality of Life, Caregiver Well-being, and Health Care UseJAMA Internal Medicine, 2019
- Does Caregiving Strain Increase as Patients With and Without Dementia Approach the End of Life?Journal of Pain and Symptom Management, 2019
- A Call to Bridge Across Silos during Care TransitionsThe Joint Commission Journal on Quality and Patient Safety, 2018
- Development and testing of the Dementia Symptom Management at Home (DSM-H) program: An interprofessional home health care intervention to improve the quality of life for persons with dementia and their caregiversGeriatric Nursing, 2016