Tuesday, July 1, 2025 7/1/2025

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

Award Number: R01NR017636
ORGANIZATION: NATIONAL INSTITUTE OF NURSING RESEARCH
OPDIV: NIH
AWARD CLASS: DISCRETIONARY
AWARD ACTIVITY TYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)
PERIOD OF PERFORMANCE START DATE: 08/09/2024
PERIOD OF PERFORMANCE END DATE: 05/31/2028

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Transitional Care for Skilled Nursing Facility Patients with Alzheimer’s Disease and Related Dementias and their Caregivers: a Cluster Randomized Trial. - 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. 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 in a population of 327 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 parallel arms, 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 efficacy 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 variability in Connect-Home ADRD outcomes and implementation. (3a) Determine intervention impact by patient discharge destination and other factors for caregiver and patient outcomes. (3b) Identify factors at the dyad-level (e.g., patient discharge destination) and SNF-level (e.g., quality rating) contributing to fidelity to the C-H ADRD protocol. IMPACT: C-H ADRD has potential to improve health outcomes of people with ADRD and their caregivers.


Issue Date FY	Funding FY	Legal Entity Name	Legal Entity Address	Legal Entity City	Legal Entity State	Legal Entity Zip Code	Legal Entity COUNTY	Legal Entity COUNTRY	Assistance Listing	Award Code	Budget Year	Action Date	Action Type	Action Amount

Issue Date FY: 2025 ( Subtotal = $603,849 )
2025	2025	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Nursing Research	000	6	6/25/2025	NON-COMPETING CONTINUATION	$603,849
														Subtotal = $603,849

Issue Date FY: 2024 ( Subtotal = $551,759 )
2024	2024	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Nursing Research	001	5	8/9/2024	COMPETING CONTINUATION	$630,916
2024	2021	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Nursing Research	000	4	11/28/2023	NON-COMPETING CONTINUATION	-$79,157
														Subtotal = $551,759

Issue Date FY: 2021 ( Subtotal = $411,865 )
2021	2021	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Nursing Research	001	4	4/27/2021	NON-COMPETING CONTINUATION	$411,865
2021	2020	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Nursing Research	000	3	12/18/2020	SUPPLEMENT FOR EXPANSION	$0
														Subtotal = $411,865

Issue Date FY: 2020 ( Subtotal = $874,742 )
2020	2020	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Nursing Research	000	3	4/22/2020	NON-COMPETING CONTINUATION	$493,058
2020	2020	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Nursing Research	001	3	7/9/2020	SUPPLEMENT FOR EXPANSION	$381,684
														Subtotal = $874,742

Issue Date FY: 2019 ( Subtotal = $532,871 )
2019	2019	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Nursing Research	000	2	4/30/2019	NON-COMPETING CONTINUATION	$532,871
														Subtotal = $532,871

Issue Date FY: 2018 ( Subtotal = $507,563 )
2018	2018	UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL	104 AIRPORT DR STE 2200	CHAPEL HILL	NC	27599	ORANGE	USA	Nursing Research	000	1	7/24/2018	NEW	$507,563
														Subtotal = $507,563

Grand Total All Awards = $3,482,649

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

Award Number: R01NR017636

ORGANIZATION: NATIONAL INSTITUTE OF NURSING RESEARCH

OPDIV: NIH

AWARD CLASS: DISCRETIONARY

AWARD ACTIVITY TYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)

PERIOD OF PERFORMANCE START DATE: 08/09/2024

PERIOD OF PERFORMANCE END DATE: 05/31/2028

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