Evaluation of a transition care cognitive assessment and management pilot.

This paper describes the evaluation of the Transition Care Cognitive Assessment and Management Pilot (TC CAMP) at a residential care facility in Victoria, Australia. Transition care aims to provide a goal-oriented, time-limited service to older people at the conclusion of an episode of hospital care. The TC CAMP was established to specifically meet the needs of people with cognitive impairment. The purpose of this study was to evaluate the implementation and effectiveness of the TC CAMP. The evaluation sought to explore the perceptions of staff and family carers, and outcomes for the person with dementia. Methods consisted of file audits, focus groups and individual interviews with nursing staff and carers. This evaluation found that it was possible to provide appropriate transition care to people with cognitive impairment who exhibited behavioural and psychological symptoms of dementia. The TC CAMP achieved length of stay and readmission rates that were comparable with transition care for cognitively intact people. The role of the Clinical Nurse Consultant was highly valued by staff and families involved in TC CAMP. The findings from TC CAMP suggest a suitable environment, availability of trained and resourced nursing and clinical staff and clear roles and expectations for all stakeholders should be considered in implementation of this model of care.