ABOUT

 Our Major Goal

ED-LEAD seeks to improve the care of persons living with dementia (PLWD) and their informal care partners by addressing emergency and post-emergency care through different combinations of three PLWD-care partner dyad focused interventions:

1) Emergency Care Redesign (ECR);

2) Nurse-led Telephonic Care (NLTC); and

3) Community Paramedic-led Transitions Intervention (CPTI)

All three interventions identify and address social determinants of health. Though the interventions otherwise differ, the primary function is to use coaching to help connect PLWD and their care partners with community support and services to improve transitional care, quality of care, care satisfaction and reduce future ED visits and hospitalizations.

We will evaluate the effectiveness of these three interventions on the following outcomes:

1) ED revisits within 30 days (primary outcome), 14 days, and 6 months (secondary) of discharge; 2) Hospitalization within 14 days, 30 days, and 6 months of discharge (secondary); and 3) Healthy days at home within 6 months of discharge (secondary).