Hospital-to-home transitions for older adults with dementia and multiple chronic conditions face major challenges due to systemic healthcare gaps, according to a comprehensive review published in BMC Geriatrics. The study analyzed 70 documents to understand how these critical transitions work for patients with multiple long-term conditions and dementia.
Healthcare professionals, including geriatric specialists, frequently lack adequate dementia training, the research revealed. According to the review, this knowledge gap affects providers’ ability to identify and diagnose dementia, which the review links to poor discharge planning and higher readmission risk. The review found that limited dementia knowledge made it difficult for many providers to create a hospital-to-home care plan or manage co-existing conditions.
The analysis found no standardized approach for documenting or sharing dementia diagnosis information between healthcare providers. Different electronic health record systems and nonstandardized terminology create barriers, with healthcare professionals working outside of geriatric care often unaware of patients’ dementia diagnoses, according to the findings.
Family caregivers face significant challenges during these transitions, the research shows. They often assume medical responsibilities such as administering treatments, monitoring blood sugar and giving insulin injections without receiving proper training. The study associated this situation with increased emotional distress for caregivers and a higher risk of hospital readmission when care needs went unmet.
According to the findings, hospital admission and discharge procedures often prioritize the primary diagnosis and overlook dementia symptoms such as cognitive decline and behavioral issues. The review found that care plans often prioritized the admission diagnosis and failed to integrate dementia with the management of other chronic conditions.
The study emphasizes that successful transitions require system-level changes including standardized reporting, single points of contact for care coordination, dementia-specific training for healthcare professionals, and tailored interventions addressing both patient and caregiver needs.
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