Alzheimer's Foundation of America

Alzheimer's
Foundation of America

Care Transitions

A care transition refers to a move of an individual from one setting to another. Such transitions can be unexpected or planned. An example of an unexpected transition is an acute medical emergency that requires hospitalization. An example of a planned move is a transition from home to a long-term care setting. A person living with Alzheimer’s disease or related dementia might experience one or more transitions. Planning and preparing for such transitions may help ensure the person remains safe and their needs are met throughout the process

Following are tips to help facilitate a smooth transition:

Be Prepared: Create a “go kit” that includes personal, medical, and daily living items.

Communication: Alert staff at settings of the person’s medical history (e.g., current medications, allergies, physical limitations, hearing or eyesight problems) and preferences (e.g., food, leisure and daily schedule).

Documentation: Ensure that the facility has the individual’s health and legal documents (e.g., power of attorney, Do Not Resuscitate) on-file.

Advocate: Act as an advocate, communicating the person’s known wishes or, if wishes are not known, try to make decisions that are in their best interest.

Coordination of Care: Get to know each member of the person’s medical team and understand their responsibilities in care planning. To ensure optimal care, it is important that everyone is on the same page.

Environment: Whether a hospitalization or a long-term care transition, the comforts of home can help. Photos, personal care products and other favorite items can make a new space feel more familiar and personal.

Observe: A transition can be overwhelming and can affect a person’s overall wellbeing, causing changes in mood and behavior. Lessen these changes by helping with the adjustment by brining personal items.

Resources: Familiarize yourself with community support services (e.g., home care, Meals on Wheels) to ensure the person’s safety and immediate needs are met.

Follow Up: Speak with the medical team throughout the entire transition process.

Support: Be supportive by remaining calm and attentive. Showing the person love and care can help them adapt to the changes.