Dementia Transition Model

Theoretical Framework of Dementia Transitional Care

Patients and their caregivers are often the only common factor moving across healthcare settings and it is important to create a transition model intended to improve care transitions and involve both patients and caregivers (Coleman, Smith, Frank, et al., 2004). Research on theoretical frameworks specifically on transitional care for persons with dementia is limited. In a systematic review, Enderlin et al. (2013) summarized six different transitional care models for older adults. Out of these six, four of the models of transitional care were geared for older adults transitioning from hospital to home; the fifth was specific from clinic to home and last model was from nursing home to hospital.

It includes both hospital planning and home follow-up in partnership with the client and family. In fact the highlight of TCM is client-family understanding and management of health problems, identification and response to potential issues to prevent deterioration in client health status (Enderlin, et al., 2013; Naylor, et al, 2014). TCM has been demonstrated to reduce ED visits, hospital readmissions, and hospital costs in three different randomized controlled studies (Naylor, et al.,

The TCM was comprised of an advanced practice nurse implemented intervention in hospital, up to 2 months post-discharge follow-up including hospital and home visits by the advanced practice nurse, at least one follow-up visit with a physician, telephone outreach and phone availability every day of the week. TCM was demonstrated to have significantly decreased (all cause) re-hospitalization or death, lower mean re-hospitalization rates per person and result in consistently fewer re-hospitalizations compared to the other two models on the study (Naylor et al., 2014). Using randomized controlled trials, the TCM answers its research questions using a positivist and post-positivist perspectives. In positivist perspective, inquiry is based upon scientific observation; and ideas only deserve incorporation into knowledge if they can be put to the test of empirical experience (Crotty, 1998). Assuming a positivistic standpoint is not only about implementing certain approaches to the design of research studies, but also, as Crotty (1998) describes, positivist perspective implies that the results of research will tend to be presented as objective facts and established truths. In post positivist perspective, the research results do not have absolute certainty; the methods used in research in