# Transitional Care for Skilled Nursing Facility Patients with Alzheimer’s Disease and Related Dementias and their Caregivers: a Cluster Randomized Trial.

> **NIH NIH R01** · UNIV OF NORTH CAROLINA CHAPEL HILL · 2024 · $630,916

## Abstract

Project Summary/Abstract
Every year 400,000 people with Alzheimer’s disease and related dementias (ADRD) are hospitalized, transfer
to a skilled nursing facility (SNF), and transition to home, assisted living, or long term care. After discharge,
one in five patients are re-hospitalized within 30 days, and their caregivers experience high levels of strain and
psychological harm. Black SNF patients and caregivers, compared to their White counterparts, experience
lower access to ADRD care and worse outcomes after SNF discharge. To promote effective transitions from
SNF to home and other destinations, we designed the Connect-Home ADRD transitional care intervention (C-
H ADRD), an adaptation of Connect-Home transitional care. Our recent trial of Connect-Home generated
evidence for intervention efficacy and reach in a population of Black and White patient and caregiver dyads. In
a supplemental award, we identified unique needs of SNF patients with ADRD and their caregivers. We
designed the C-H ADRD intervention to address those needs: (1) before discharge, SNF staff develop an
ADRD transition plan with patient and caregiver dyads and (2) after discharge, a Dementia Caregiving
Specialist provides phone-based support for the ADRD transition plan. In a pilot study, we demonstrated C-H
ADRD’s feasibility, acceptability, and potential to reduce caregiver strain and patient neuropsychiatric
symptoms (NPS). The next logical step is an efficacy test of C-H ADRD. Our Objective is to conduct a cluster
randomized trial (CRT) of C-H ADRD, enrolling 360 ADRD patient and caregiver dyads in 12 SNFs.
The Specific Aims are:
Aim 1: Conduct an CRT of C-H ADRD (intervention) vs. usual discharge planning (control) and compare
caregiver outcomes 30 days after discharge: (1) caregiver strain (primary) and (2) depression and
preparedness for care transitions (secondary).
Aim 2: Compare patient outcomes between intervention and control arms 30 days after discharge: (1) patient
NPS (primary) and (2) quality of life and acute care use (secondary). Exploratory: Examine whether caregiver
strain modifies intervention effect on patient outcomes.
Aim 3: Examine potential disparities by race in Connect-Home ADRD outcomes and implementation. (3a)
Determine intervention impact by patient race and other factors for caregiver and patient outcomes. (3b)
Identify factors at the dyad-level (e.g., social determinants) and SNF-level (e.g., staffing) contributing to fidelity
to the C-H ADRD protocol.
IMPACT: C-H ADRD has potential to improve health outcomes and health equity for people with ADRD and
their caregivers.

## Key facts

- **NIH application ID:** 10979866
- **Project number:** 2R01NR017636-05A1
- **Recipient organization:** UNIV OF NORTH CAROLINA CHAPEL HILL
- **Principal Investigator:** LAURA C HANSON
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2024
- **Award amount:** $630,916
- **Award type:** 2
- **Project period:** 2024-08-09 → 2028-05-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10979866

## Citation

> US National Institutes of Health, RePORTER application 10979866, Transitional Care for Skilled Nursing Facility Patients with Alzheimer’s Disease and Related Dementias and their Caregivers: a Cluster Randomized Trial. (2R01NR017636-05A1). Retrieved via AI Analytics 2026-06-12 from https://api.ai-analytics.org/grant/nih/10979866. Licensed CC0.

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