The Emergency Departments LEading the Transformation of Alzheimer’s and Dementia (ED-LEAD) programs are meant for patients 65 and over who have received a diagnosis of dementia indicative of changes in memory or thinking and who are discharged home from the emergency department. The programs are voluntary and free to patients. Emergency departments participating in the trial are running the programs as one, a combination of two, or all three.

Emergency Care Redesign

Emergency Care Redesign is a team-based program grounded in evidence-based practice to improve the care of persons living with dementia who present to the emergency department. This program seeks to improve communication between health care providers and their patients and care partners. The ED care team meets together with patients at the bedside to better understand the present problem and identify the best strategies. At discharge, patients and their care partners are provided with information about community resources, and patients receive a follow-up call from an ED contact within three days of discharge.

Key features of ECR include:

• Targeted alerts to ED providers that the patient has special brain health needs
• Assessment tools and strategies added to the Electronic Health Record supporting doctors and nurses in providing optimal care to persons living with dementia
• Care team huddles where the patient’s needs and goals are discussed together with the patient and care partner
• Post-discharge community resources and a care continuity follow-up phone call

Community Paramedic-led Transitions Intervention (CPTI)

The Community Paramedic-led Transitions program is a 30-day coaching intervention delivered by community paramedics after an eligible patient is discharged from the emergency department . The CPTI program leverages the evidence-based Care Transitions Intervention and is designed to empower persons living with dementia and their care partners to develop the necessary skills and confidence to actively manage their health. In the CPTI, community

paramedics collaborate with persons living with dementia and their care partner(s) to set goals, build skills, and strengthen confidence in areas critical to managing their health at home.

Key features of the CPTI include:

• A home visit from a community paramedic within approximately 5 days of emergency department discharge and 3 follow-up phone calls for up to 30 days
• Patient-centered coaching focused on improving medication management, ensuring timely outpatient follow-up, responding appropriately to health conditions, and enhancing communication with healthcare providers

Nurse-Led Telephonic Care (NLTC)

Nurse-Led Telephonic Care is a comprehensive telehealth program designed to provide care and support for persons experiencing changes in thinking including dementia and their care partners after discharge from the emergency department. Specially trained telephonic nurses check in with patients by phone according to a structured program, tailored to the unique needs of the patient and care partner, for up to 6 months. The program encompasses training, care plans, assessment instruments, treatment algorithm, and education materials delivered through phone calls, interdisciplinary team meetings, and a learning network of nurses implementing the program.

Key features of NLTC include:

• Assessing the needs of patients and their care partners
• Personalized care plans to help the patient and care partner succeed at home, improve their quality of life and support their goals of care
• Help the patient and care partner navigate the healthcare system
• Providing referrals to supportive community resources

Study Cores

To support the important work of our programs, the study leverages three Cores: an Implementation Core, a Statistical Analysis Core, and an Administrative Core.

Implementation Core supports the readiness of each site through a tailored implementation blueprint in accordance with the study protocol and monitors program fidelity across partnering health systems. This includes detailed manuals of procedure that describe implementation strategies and how planned and unplanned adaptations will be managed, measured, documented, and reported over time. The Implementation Core, in coordination with the Administrative Core, oversees the fidelity of each program to ensure all core functions are performed within each of the ED-LEAD programs. In addition, the Core closely guides the design and function of clinical decision support tools in the electronic health record.

The Statistical Analysis Core develops the modeling framework that will enable evaluation of each program individually and in combination. This Core supports data management related to patient-level health utilization data, training and program fidelity, non-CMS, program-specific

patient-level outcome measurement, and program-specific implementation outcome measurement. Core staff performs statistical analyses and data exploration using appropriate statistical and computing methodologies and assist in interpreting and presenting results.

The primary role of the Administrative Core is to ensure efficient and effective coordination between the programs; facilitate effective partnership with and support for partnering health systems carrying out the study; and disseminate the findings of this work to make the information widely available and applicable.

Research related to ED-LEAD is supported by the National Institute on Aging (NIA) of the National Institutes of Health (NIH) under Award Number: U19 AG078105-01A1.

The content is solely the responsibility of the study principal investigators and does not necessarily represent the official views of the National Institutes of Health.