Improving hospital transitions for older adults with memory loss

This study is testing whether a quality improvement program called CoMPAS+ can help healthcare teams better coordinate care when older adults with major neurocognitive disorders (like Alzheimer's disease and dementia) move between hospitals, home care, and other care settings. Researchers will work with doctors, nurses, and caregivers in two communities to redesign how care is handed off, and then measure whether fewer patients experience problems like unexpected hospital readmissions.

Many older adults with memory disorders experience dangerous gaps in communication when moving between different parts of the healthcare system — from the emergency room to home care, or from one doctor to another. This leads to readmissions, worsening health, and stress for families. This trial exists to test whether better teamwork and communication can smooth these transitions.