Transitions of Care: Dementia Part 2

1. Education and Discharge Planning for the Resident With Dementia or Cognitive Impairment

This chapter will focus on the role of the nursing staff and other members of the interdisciplinary team to enable residents and/or their caregivers to manage care if they return home. Additional focus will be on appropriate interventions to prevent acute care hospitalizations since those events are often overwhelming for residents and can result in delirium, compromised function, longer-than-average hospital stays, and poor post-discharge outcomes.

2. Individual Resident and Caregiver Goals Related to Prognosis and Potential for Rehabilitation

This chapter will focus on individual resident and/or caregiver goals based on the resident's prognosis and potential for rehabilitation. The importance of advance care planning, hospice, and palliative care will be included, with a discussion of guidelines for hospice qualification.

3. Interactive Case Study

The case study will summarize and synthesize the learning related to the high-risk resident with dementia in the NF. Interactive technology will allow the learner to use his/her knowledge and skills to provide quality care and prevent unnecessary hospitalization for a complex resident with dementia.