A Trial of the C-TraC Intervention for Dementia Patients

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