# Bridging Communication Gaps between Primary Care Providers and Adult Day Service Centers to Reduce Emergency Department Use and Hospitalizations among Persons with Dementia

> **NIH NIH R21** · NEW YORK UNIVERSITY · 2020 · $396,250

## Abstract

PROJECT SUMMARY
Community-dwelling persons with Alzheimer’s Disease and Alzheimer’s disease-related dementias (AD/ADRD)
are more susceptible to avoidable emergency department (ED) visits and hospitalizations than individuals in
institutional settings. Adult day service centers (ADCs) provide community-based care to a growing number of
highly vulnerable adults with AD/ADRD. Daily assessment and serial observations by the ADC’s interdisciplinary
staff support early detection of adverse changes in health status in people with chronic conditions. However,
when acute changes in users’ health status occur, ADC staff who wish to provide timely notification to primary
care providers (PCPs) in order to facilitate early intervention, frequently cannot do so effectively. As the number
of persons with AD/ADRD is expected to triple by 2050 and most remain in the community, there is a critical
need to strengthen communication of salient clinical information between ADCs and PCPs in order to reduce
costly hospitalizations and ED visits. Mobile health (mhealth) interventions can improve healthcare communica-
tion processes by eliminating barriers to real-time bidirectional information exchange across a variety of settings.
Yet, we previously found that ADC staff relied on facsimile or voicemail message to communicate abnormal
blood pressures or acute changes in users’ behavior, resulting in a delayed or non-response from the PCP. This
allowed minor health issues to escalate into medical emergencies. The objective of the proposed mixed-methods
sequential explanatory study, guided by the ehealth Enhanced Chronic Care Model (eCCM), is to inform the
development of a future low-cost mobile application that facilitates transdisciplinary communication between
ADCs and PCPs around key risk factors for poor health outcomes in ADC users with AD/ADRD. The following
are the specific aims: (1) Determine health and social risk factors that are associated with ED visits and hospi-
talizations among ADC users living with AD/ADRD over a one-year period; (2) Explore barriers and facilitators
of meaningful communication between ADC staff and PCPs around risk factors associated with ED visits and
hospitalizations in persons with AD/ADRD; (3) Identify the key domains of a future mhealth intervention that
supports communication between ADCs and PCPs surrounding risk factors associated with ED visits and hos-
pitalizations in persons with AD/ADRD. In Aim 3, we anchor the findings from Aims 1 and 2 within an mhealth
framework to conceptually to map key domains of a future mhealth intervention that will support productive com-
munication between PCPs and ADCs around risk factors for ED visits and hospitalizations in persons with
AD/ADRD. This study is significant because improved communication across community-based providers can
support early clinical intervention, improve standards of care, and thwart costly adverse outcomes for a highly
vulnerable subset of persons with AD/ADRD. This...

## Key facts

- **NIH application ID:** 10093706
- **Project number:** 1R21AG069801-01
- **Recipient organization:** NEW YORK UNIVERSITY
- **Principal Investigator:** Tina Sadarangani
- **Activity code:** R21 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $396,250
- **Award type:** 1
- **Project period:** 2020-09-30 → 2022-05-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10093706

## Citation

> US National Institutes of Health, RePORTER application 10093706, Bridging Communication Gaps between Primary Care Providers and Adult Day Service Centers to Reduce Emergency Department Use and Hospitalizations among Persons with Dementia (1R21AG069801-01). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10093706. Licensed CC0.

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