# Adapting Connect-Home Transitional Care to Fit the Unique Needs of Persons with Alzheimer's Disease and Other Dementias and their Caregivers: A Pilot Study

> **NIH NIH R01** · UNIV OF NORTH CAROLINA CHAPEL HILL · 2020 · $381,684

## Abstract

PROJECT SUMMARY/ABSTRACT
Persons with Alzheimer’s disease and related dementias (AD/ADRD), who receive care in skilled nursing
facilities (SNF), are a medically complex population with substantial dependence on family caregivers. Despite
the high prevalence of acute care use and mortality after persons with AD/ADRD return home, no studies
designed or tested transitional care to prepare persons with AD/ADRD and their caregivers for transitions from
SNFs to home. In the parent study (Connect-Home Clinical Trial [R01NR017636]), we are conducting the first
efficacy trial of transitional care for seriously ill persons receiving SNF care and their caregivers. The objectives
in this supplement are: (1) to adapt Connect-Home for the unique transitional care needs of persons with
AD/ADRD and their caregivers and (2) to study the feasibility, acceptability, and outcomes of the adapted
intervention. Our central hypothesis is that by applying a systematic, stakeholder-engaged approach, we will
adapt Connect-Home to support the delivery of transitional care to meet the distinct care needs of persons with
AD/ADRD and their caregivers. The rationale for this study is that adapting and testing Connect-Home will
generate a new model of transitional care for a future efficacy trial. We propose two specific aims: (1) engage
diverse stakeholders to identify unmet needs or persons with AD/ADRD and their caregivers and co-produce an
adapted version of the Connect-Home intervention for persons with AD/ADRD and their caregivers; and (2)
determine the feasibility and acceptability of the adapted intervention and estimated mean outcomes of persons
with AD/ADRD and their caregivers. The setting for the study will be four SNFs that currently use the Connect-
Home intervention. The sample will include (1) persons with AD/ADRD, (2) caregivers (e.g., family members) of
persons with AD/ADRD, and (3) SNF and home care staff. In Aim 1, we will engage a steering committee
(comprised of academic, SNF/home care and caregiver stakeholders), use mixed methods to identify unmet care
needs of persons with AD/ADRD and their caregivers, and adapt Connect-Home to address those unmet needs
while retaining fidelity to its program theory. In Aim 2, we will implement adapted Connect-Home tools and staff
training in two SNFs and a home care agency and study (1) the feasibility of the adapted intervention (using
adapted chart review measures from the parent study) and the (2) acceptability of the intervention (using surveys
with 20 persons with AD/ADRD, their 20 caregivers, and staff). We also will study patient and caregiver outcomes
of the adapted intervention using measures in the parent study (i.e., patient preparedness for discharge and
preparedness for caregiving; patient quality of life, function, days of acute care use; and caregiver burden and
distress).

## Key facts

- **NIH application ID:** 10123392
- **Project number:** 3R01NR017636-03S1
- **Recipient organization:** UNIV OF NORTH CAROLINA CHAPEL HILL
- **Principal Investigator:** Mark P Toles
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $381,684
- **Award type:** 3
- **Project period:** 2018-07-25 → 2022-04-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10123392

## Citation

> US National Institutes of Health, RePORTER application 10123392, Adapting Connect-Home Transitional Care to Fit the Unique Needs of Persons with Alzheimer's Disease and Other Dementias and their Caregivers: A Pilot Study (3R01NR017636-03S1). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10123392. Licensed CC0.

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