How can we tackle inequalities in transitions between hospital and home for people living with dementia?

The Centre for Applied Dementia Studies recently had a fantastic visit from Associate Professor Amy Kind. The Bradford Doctoral Training Centre is supported by a number of internationally recognised scholars in transitions in dementia care. Amy is one of those visiting scholars, who encouraged us to consider ‘how can we tackle inequalities in transitions between hospital and home for people living with dementia?’

Amy is an Associate Professor within the Division of Geriatrics and Director at the Department of Medicine Health Services and Care Research Program in the University of Wisconsin School of Medicine and Public Health. Amy is also Associate Director for Clinical Operations at Madison VA Geriatrics Research Education and Clinical Center (GRECC).

Learning about Hospital to Community work for People Living with Dementia

Amy began her visit by giving a public lecture about her work on ‘Improving Quality of Life and Health Outcomes at Transition from Hospital to Community for People Living with Dementia’. See Amy’s lecture slides here: Amy Kind Public Lecture_2018

We learnt about the disparities in health in the US and Amy’s work to ‘develop practical approaches towards the elimination of health disparities’. Improving outcomes at transition are key to this. Amy highlighted the importance of thinking beyond the point of discharge from hospital, and focusing more on ensuring that there is better ongoing support in place. People living with dementia may find transitions particularly challenging. For example, they might have more difficulties in adapting across to new settings.

The ‘Coodinated-Transitiional Care Program (C-Trac)’ has been developed by Amy and her colleagues to improve transfers between hospital and home. It does so through a variety of methods including, educating people living with dementia and carers about red flags and how to manage their medication, ensuring there are medical follow ups and that both people living with dementia and carers know who to turn to if they have any queries. The program was tested and showed less emergency room visits, more visits to clinicians and patient satisfaction (Kind, 2018).

Many of our doctoral training centre students had meetings with Amy. Doctoral training centre student, Angela tells us about what she learnt from meeting with Amy and attending her masterclass…

Speaking to an expert in the field you are undertaking research in is an enormous privilege. I was familiar with Amy’s work as I had read about her research when undertaking my literature review for my own project. Meeting ‘experts’ can be intimidating, but this was not the case with Amy, she made me feel at ease and showed great enthusiasm for my study. My project is about exploring nurses’ perceptions of the role of nurses in optimising the transition between hospitals and nursing homes for people living with dementia.  I will be interviewing and undertaking focus groups with nurses in both hospitals and care homes. She had been involved in similar projects in the US and she gave me some great tips about carrying out my research. She suggested undertaking my care home exploration first, as this would help me to develop vignettes to support my exploration of hospital nurse perceptions. Without such valuable insight I would not have planned to do this, I am so grateful for the tip. She gave me other practical ideas too about the topics I may want to consider for my focus groups, and she was able to pass on some challenges I may come across. My meeting with Amy was invaluable.

Amy also held a masterclass titled ‘Improving care transitions from hospital to community for disadvantaged US populations’ Students and supervisors spent the morning together listening to Amy about this interesting and thought provoking topic. Her class stimulated much discussion about identifying disadvantaged populations, and that often clinical teams over-look this. It led onto a discussion about how do we target needed services at the population level? We learned that people from disadvantaged groups were more likely to need higher level of support after hospitalisation and they may not be able to access them in their local communities. We heard more about the implementation of the C-TRAC programme and how Amy and her team have rolled it out to systems in parts of the US. The discussion about implementation was illuminating, as we know translating research findings into practice can be difficult. Some of the success factors she shared with us was attending to details in the pre-intervention phase such as the importance of engaging with multi-disciplinary local stakeholders, enabling them to set the local outcomes that need to be achieved. She talked about ensuring any service improvement is integrated with the current processes with the local healthcare system, and to plan on adapting any intervention to fit in it. It is important to spend time with teams, to recruit champions who can help implement the programme, on-going mentorship being vitally important. This is just a taster of what we learned on what was a very enlightening and energising master-class.


Watch this space…

Amy’s visit is just one of a series of visits from the International Advisory Panel that the Centre for Applied Dementia Studies regularly have. We look forward to a visit from Professor Steven Zarit from Penn State University on the 18th to the 20th June. Steven will also hold a public lecture during his visit. To attend this event, look out for more information on the centre’s webpages coming soon.


Written by Angela Richardson and Catherine Powell

Angela Richardson is a second year doctoral training centre student. She has a background in mental health nursing with a special interest in dementia care and practice development.

Dr Catherine Powell is a Research Fellow at the Centre for Applied Dementia Studies.



Kind, A (2018) ‘Improving Quality of Life and Health Outcomes at Transition from Hospital to Community for People Living with Dementia’ [PowerPoint presentation]