PartnerED Care: Coordinated Emergency Department Transitions for Assisted Living Patients With Alzheimer's Disease and Related Dementias
Phase: NA
Conditions: Alzheimer Disease or Associated Disorder
Sponsor: Brown University

 
 
 
 
PartnerED Care: Coordinated Emergency Department Transitions for 
Assisted Living Patients With Alzheimer's Disease and Related 
Dementias 
 
NCT06933849 
 
 
 
 
September 1, 2023 

 
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BACKGROUND 
For over 800,000 older adults in the US, assisted living communities (ALCs) serve as substitutes for nursing 
homes.1 Over time, ALC residents have become increasingly medically complex, with higher rates of 
comorbidities and cognitive impairment.2 Over 80% of ALC residents have three or more comorbidities and 
rates of heart failure, diabetes, and COPD similar to long-stay nursing home (NH) residents.1 Though there is 
significant variability across geography and corporations, ALCs are generally staffed 24 hours a day and 
provide room, board, structured activities and basic IADL/ADL support.3 Clinical services are delivered by 
external provider groups, with several groups serving each ALC.  
  
The emergency department has become a key resource for this population, with 49% of ALC residents visiting 
the emergency department (ED) at least once each year.4 With each transition in care, including from ALC-ED, 
there is increased risk of duplicative testing, delays in care, and avoidable hospitalizations due to incomplete or 
inaccurate  information during transfer.5 These care transitions are particularly fraught for vulnerable patient 
populations, particularly those living with dementia.6 Due in part to greater complexity of chronic diseases and 
fractured care, residents of ALCs commonly experience higher rates of ED utilization, longer stays in the ED, 
and higher resource utilization within the ED than older adults not living in ALCs or long-term care facilities.7,8 
For these older adults, increased ED and hospital utilization is consistently associated with adverse outcomes 
including delirium, falls, and accelerated cognitive and functional decline.9-11  
  
Previous care transition interventions have included staff education to prevent ED visits, standardized 
communication tools, computer-based networks, and home visits after ED discharge.12-15 One such 
intervention is the Intervention to Reduce Hospitalization from Nursing Homes (INTERACT), a widely accepted 
and studied quality improvement tool for nursing home (NH)-ED transitions, that has been demonstrated to 
decrease all-cause hospitalizations by up to 24%.16  INTERACT is a complex intervention that includes multiple 
components including educational and clinical strategies to improve NH to ED transfers. Despite its complexity, 
it has been successfully implemented in a variety of nursing homes.17-19 However, similar programs have yet to 
be implemented for ALC-ED transfers. 
  
PartnerED care, a pragmatic care coordination intervention for ALC residents with dementia was adapted from 
the NH-ED structured communication component of INTERACT to support standardized, closed-loop 
communication between the ALC outpatient team and ED provider.7,8 Through improved communication at the 
time of ALC to ED transfer, PartnerED care aims to reduce hospitalizations within ALC residents. PartnerED 
care creates a structure in which acute care managers (ACM) will be notified electronically when a resident 
registers at an ED and will provide key information through a standardized form over the phone regarding the 
patient and available outpatient resources to the ED clinician. In the proposed embedded pragmatic clinical 
trial pilot, we will evaluate the feasibility of implementing PartnerED care for patients served by Bluestone 
Physician Services (Bluestone). We will evaluate feasibility, appropriateness, acceptability, and adherence 
through qualitative interviews with practitioners and key stakeholders, quantitative surveys using validated 
tools, and key adherence metrics, These metrics will be captured through a user-defined assessment (UDA) 
within Bluestone’s EMR and will include timing and number of phone calls placed by ACM, type of ED staff 
contacted, and the ultimate disposition. Further, we will assess our ability to obtain EMR- and claims-based 
patient-centered outcomes for a future ePCT. 
 
SIGNIFICANCE 
The PartnerED intervention is innovative, and aligns with the IMPACT Collaboratory priorities, in the following 
three ways: 
1. Leveraging technology - Uses real-time nudges (electronic notifications sent directly to ACM) to trigger 
intervention.  
2. IMPACT priority setting (ED) - Modify best practice ED tool for NHs to the ALC setting, an underserved 
sector of the IMPACT portfolio 
3. IMPACT established Launchpad partner - Bluestone-driven initiative emerging from a Collaboratory 
Launchpad partnership, including leveraging data from MEDRIC 
 
 
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RESEARCH DESIGN AND METHODS 
The goal of this study is to pilot a care coordination intervention in approximately 300 EDs for 5,500 patients 
living in approximately 240 ALCs in Florida (FL), Wisconsin (WI), and Minnesota (MN). The population for this 
pilot will not be randomized. All Bluestone ACO patients with ADRD who have an ED visit during the 
enrollment window will be included in the analyses. The intervention will only be offered Monday through 
Friday, between 8 am and 4 pm. Feasibility, appropriateness, and acceptability will be assessed quantitatively 
and qualitatively. Qualitative, semi-structured interviews will be conducted with four Bluestone ACMs, four 
Bluestone physicians, four ALC staff, and four ED providers involved in the pilot, to understand barriers and 
facilitators to implementing the PartnerED program. Feasibility, appropriateness, and acceptability will be 
assessed quantitatively by surveying all Bluestone ACMs and physicians involved in the program using the 
Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of 
Intervention Measure.20,21 
 
The primary clinical outcome will be the proportion of ED visits that result in hospital admissions based on 
documentation in the Bluestone EMR. Secondary clinical outcomes include proportion of ED visits that result in 
hospital admissions, length of ED stay in hours by hospital, proportion of eligible ED visits with an ED return 
visit within 72 hours, and proportion of eligible ED visits with a subsequent hospitalization in the following 60 
days based on CMS claims data. Preliminary outcome analyses will compare Bluestone ACO residents with 
ADRD (intervention) to Bluestone’s non-ACO, fee-for-service Medicare patients with ADRD, which is 
approximately equal in size of the ACO population.  
 
Setting (Sites/Heath Care Systems) 
Bluestone delivers 500-600 provider visits per day for over 15,000 patients in ALCs across three states (MN, 
WI, FL). Approximately 70% of the patients they serve have a dementia diagnosis. Approximately 30% of 
Bluestone’s patients qualify for Medicaid and over 90% are enrolled in Medicare FFS or Medicare Advantage. 
Bluestone manages its own Medicare (MSSP) Accountable Care Organization, Bluestone ACO, which 
currently enrolls approximately 5,500 patients. Bluestone has experienced significant growth in patient census, 
averaging growth of 8% year over year for the past 4 years.  
 
Study population 
Table 1 shows the demographic and health characteristics of Bluestone patients. 
They are on average 81 years old, 70% female, and 69% have ADRD. 
Approximately 35% of ED visits for this population result in hospital admission. In 
2022, 7,272 ED visits by Bluestone ACO patients were attributed to its 65,886 total 
member months for this population, or 1.3 ED visits/patient year. Of these ED visits, 
49% were for ALC residents in Florida, 35% in Minnesota, and 15% in Wisconsin. 
Bluestone residents have other comorbid conditions that increase risk of 
hospitalization including 31% with diabetes; 18% with chronic obstructive pulmonary 
disease (COPD); and 37% with heart failure. Based on previous research done 
within Bluestone’s ADRD population, the racial and ethnic composition is different 
from national averages (81% white, not-Hispanic compared to 91%). However, we 
expect this to be more similar once we can fill in missing race/ethnicity data (14% of 
sample) from the linked claims data that will be available through MedRIC. 
 
During the six-month pilot intervention window, we anticipate approximately 2,500 daytime ED visits excluding 
weekends by Bluestone ACO patients. Based on the prevalence of ADRD and the racial and ethnic 
composition of Bluestone ACO patients, we expect a sample size of 1750 ED visits for Bluestone ACO patients 
with ADRD and 130 ED visits for patients identified as a racial or ethnic minority (i.e. not white, non-Hispanic).  
 
Intervention structure, implementation protocol, and fidelity/adherence monitoring plan 
To develop PartnerED, we adapted standardized communication tools used for acute care visits by long stay 
residents from INTERACT, a QI intervention to reduce hospitalizations, using the FRAME framework.16,22,23 
These proactive modifications were made based on discussions between researchers and Bluestone 
(including clinical providers, administrative leadership, and the data team). Modifications were made largely 
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due to differences in the context of delivery of the intervention. Specifically, we have created a script adapted 
from the INTERACT version 4.5 Hospital transfer form, data list, and checklist that includes key clinical 
information (Table 2) and patient services available as next day primary care appointment and immediate 
behavioral health referral. 
Of note, INTERACT is a multicomponent intervention designed to be 
implemented by nursing home staff.16,23 PartnerED utilizes the 
standardized communication script alone. By excluding key educational 
and clinical pathway elements, the fidelity to INTERACT is unknown. 
However, there is a robust literature supporting the use of standardized 
communication with care transitions.24  
 
This intervention leverages several unique features of the Bluestone’s 
EMR system including an electronic notification system for ED registration, 
Bridge ADT message and email, and existing case management staff 
(acute care managers - ACMs), who can implement the intervention. For 
this pilot, ACMs employed by Bluestone will monitor emails and Bridge 
messages for notification of ED registration by study participants.  Once notified that a patient is in the ED, 
ACMs will complete a chart review within the Bluestone EMR. The ACM will then call within 60 minutes of ED 
registration during business hours (8:00AM - 4:00PM) and relay clinical information related for expedited 
assessment to the ED clinical team. 
 
Bluestone will build a user-defined assessment (UDA) within their EMR to capture important adherence and 
outcome information, including ACM call within one hour of ED registration; successful contact by ACM with an 
ED provider; ED disposition, type of ED staff contacted, and primary care team updated. This UDA will be 
utilized by ACMs to track pilot participants and document implementation outcomes. These data will be sent to 
Brown weekly for adherence monitoring. Specifics for the chart review including locations of key information for 
patients, scripts for communication with the ED, and documentation guidelines will be written to policy and 
procedure templates and shared with ACM staff via training modules.  
 
Data Sources, Elements, and Collection Protocol 
Bluestone EMR and MedRIC: Patient identification (aim 1), Adherence metrics (aim 2b), and Clinical 
outcomes (aim 3) 
Bluestone is unique among ALC provider groups in that it has an integrated EMR. Bluestone’s self-hosted 
EMR data contains detailed information on patient demographics, physical and cognitive function, active 
condition lists (including dementia diagnoses), medication administration records, documentation of advance 
directives and hospice use, and other medical orders. As a part of this pilot project, a UDA will be developed 
and utilized for all patients participating. ACMs will track adherence metrics within the UDA (Table 3). 
 
As a NIA IMPACT Launchpad 
partner, Bluestone will send their 
complete EMR record, including UDA 
data, to MedRIC - the Medicare and 
Medicaid Resource Information 
Center (MedRIC) on a weekly basis. 
Brown analysts will use these data for 
routine monitoring of adherence and 
evaluation of outcomes. Claims data 
will also be collected via MedRIC 
during the study period. Rather than 
request CMS data through the typical 
process, which is prohibitive to this 
pilot structure given its cost and 
months-long approval process, NIA 
has arranged a program whereby NIA 
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funded studies that would like to merge their study data to CMS data can do so through this new program and 
use their linked data on MedRIC's secure enclave. There is no cost, the application process is relatively quick, 
and data are available with the same lag time as is available through CMS directly. To our further benefit, we 
will leverage the experience that Bluestone and Dr. McCreedy (co-I) have already gained from successfully 
setting up another project under this program. That study uses the same linked data that will be needed for this 
study.  We are cognizant of the limitations of using CMS data to measure our outcomes.  For example, all 
enrolled residents have fee-for-service Medicare claims and we anticipate a six month delay in ascertainment 
of claims for this population. See TIMELINE for details.  
 
For this pilot, we will measure our primary outcome (proportion of ED visits for Bluestone patients in a given 
hospital which result in inpatient hospitalization) based on ED disposition as tracked by the ACM within the 
UDA. This method is limited because the data may be missing or misreported. However, because of the four to 
six month lag in claims data and the need to complete the pilot within the one year timeframe, we will use this 
method as the primary outcome measure. However, we will also be able to obtain the outcomes (primary and 
secondary) for patients enrolled in months four and five. Success criteria: (1) obtaining ED disposition from the 
UDA for 85% of patients enrolled in the pilot and (2) obtaining ED disposition from CMS claims for 95% of the 
subsample enrolled in months four and five of the pilot. 
 
Quantitative: feasibility, appropriateness, and acceptability (aim 2a) 
Feasibility and acceptability will be assessed quantitatively using the Acceptability of Intervention Measure 
(AIM), Intervention Appropriateness Measure (IAM), and the Feasibility of Intervention Measure (FIM).21 AIM, 
IAM and FIM are four item measures of implementation success that were specifically designed to be 
pragmatic and have demonstrated strong psychometric properties including content validity, discriminant 
content validity, reliability, structural validity, structural invariance, known-groups validity, and responsiveness 
to change.20 Each measure has four items with a response scale from completely disagree (1) to strongly 
agree (5). The scale is created by averaging responses. This will be done separately for the AIM, IAM, and 
FIM.  
 
We will administer a survey to all Bluestone ACMs and Bluestone physicians involved in this pilot study. We 
will ask for responses with regard to the Bluestone ACO population with ADRD as well as for the Bluestone 
ACO population with ADRD when considering health-equity-relevant features including race, ethnicity, and 
socioeconomic status. 
 
Qualitative: feasibility, appropriateness, and acceptability  (aim 2a) 
Semi-structured interviews will be completed with four Bluestone ACMs, four Bluestone providers, four ALC 
staff, and four ED providers. We will make every effort to recruit participants that represent the backgrounds of 
the people delivering and receiving the intervention. 
  
Bluestone ACM Recruitment: We will ask Bluestone leadership to nominate four Bluestone ACMs to participate 
in semi-structured interviews. The research assistant will contact the ACMs recommended by corporate 
leadership, explain the study, and provide an opt-out for participation. 
  
Bluestone Provider Recruitment: We will ask Bluestone leadership to nominate four Bluestone providers 
representative of the people delivering intervention to participate in semi-structured interviews. The research 
assistant will contact the providers recommended by corporate leadership, explain the study, and provide an 
opt-out for participation. 
  
ALC Staff Recruitment: We will use the baseline EMR data to identify four ALCs (one for each staff member 
interviewed) with varying numbers of residents with dementia and numbers of residents who identify as a racial 
or ethnic minority. Bluestone leadership and/or the physician working in the ALC will approach the director to 
ask if s/he would participate in an interview. The director will nominate a member of the direct care staff for an 
interview. 
  
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ED Provider Recruitment: We will reach out to leadership teams of EDs (across the three states represented) 
that have a catchment area that is representative of people participating in the intervention. If ED leadership 
agrees, the research assistant will contact the providers recommended by ED leadership, explain the study, 
and provide an opt-out for participation. 
  
Data Collection. We will develop semi-structured interview guides which align with our study objectives, to 
include exploration of: (1) the process for Partner ED, including process for communicating with EDs by ACMs; 
(2) impressions of Partner ED intervention and its impact on patient care; (3) challenges with communicating 
with the ED; (4) impact of health-equity-relevant features of patient population served including race, ethnicity, 
and socioeconomic status. Our approach will be guided by the Practical Robust Implementation and 
Sustainability Model (PRISM) framework.25 The PRISM includes perspectives of different types of stakeholders 
to first understand their experiences while considering factors related to the external environment and 
infrastructure needed for implementation and sustainability. Drafts of interview guides will be reviewed by the 
entire team and discussed via phone conference. The final interview guide will be pilot tested to identify 
unclear questions and to ensure each interview does not exceed the allotted 30 minutes for direct care staff. 
Interviews will be digitally recorded with consent and transcribed verbatim. The IRB determined this does not 
meet the criteria for human subject research, as we are asking ACMs, Bluestone and ED physicians and ALC 
staff about their work processes and their perceptions of these processes (key informant interviews). 
 
Analytic plan.  
We will demonstrate the feasibility of identifying and enrolling ALC residents with ADRD (N=1750 ED 
visits anticipated) in real time using a pragmatic approach.  
ALC residents with ADRD will be identified pragmatically using the Bluestone EMR. We will obtain EMR data 
for all Bluestone ACO patients with an ED visit during the study period. Patients will be identified as having a 
diagnosis of ADRD using the following ICD10 codes  commonly used (primary identification strategy): F01.50-
51; F02.80-81; F03.90-91; F04; F05; F06.1; F06.8; G13.8; G30.0,1,8,9; G31.01,9; F02.80-81, F03.90-91; F04; 
F05; F06.1; F06.8; F41.81; G13.8; G30.0; G30.1,8,9; G31.01,09; G31.1-2; G31.2; G94; R54.26   
 
We will also assess the validity of our ADRD identification strategy by conducting a random medical record 
review (N=50) of two percent of patients, stratifying based on the expected 70% prevalence of ADRD within 
our population. We will review patients identified as having ADRD (N=35) and flagged as not having ADRD 
(N=15) by ICD10 codes. We will report error rate, positive predictive value, and negative predictive value. 
 
Benchmark of success: We will consider this aim completed once we have identified patients with ADRD with 
our primary identification strategy, conducted a medical record review, and calculated the error rate, PPV and 
NPV based on this review. These data will be shared with Bluestone in the form of written reports and the 
broader public through publications and conference presentations. 
 
Aim 2a. We will determine the feasibility, appropriateness and acceptability of implementing the 
PartnerED intervention for ALC residents with ADRD. 
Quantitative: For the AIM, IAM, and FIM, no specific cut-off scores have been published. A higher score is 
associated with great acceptability, appropriateness, and feasibility, respectively. We have defined success 
criteria as: 85% or greater proportion of respondents with a total score of four or higher indicating “agreement” 
or “complete agreement” with items on the AIM, IAM, and FIM.  
 
Qualitative: Interviews will be coded to predetermined (objective driven) and data generated themes.27 We will 
have weekly meetings to revise objective themes and consider additional emerging themes. Potential changes 
to interview guide or other data collection tools will also be discussed. All transcripts will be independently 
coded by two team members. Initial code definitions will be modified based on team discussions and additional 
themes will be added based on consensus vote. An audit trail will capture all changes to the coding scheme, to 
include: the date the change was made, the reason for the change, the new or revised code definition, and two 
data examples that would be coded under the new or modified theme. NVivo (QSR International, Melbourne, 
Australia) will be used for data management of coded transcripts.28 Qualitative results will be presented by 
theme and strata.  
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Benchmark of success: We will consider this aim completed once we have conducted interviews for all 
targeted participants (N=16), transcribed the interviews, performed a thematic analysis, and quantified AIM, 
IAM, and FIM for the Bluestone ACO population as well as when considering health-equity-relevant features. 
These data will be shared with Bluestone in the form of written reports and the broader public through 
publications and conference presentations. 
 
Aim 2b) We will determine adherence when implementing the PartnerED intervention for ALC residents 
with ADRD. 
Implementation adherence will be evaluated overall (among all patients with ADRD) and in a prespecified, 
minoritized subpopulation.   
 
The purpose of this pilot is to demonstrate adherence for implementation outcomes with a goal of (1) 85% ED 
visits with an ACM call within one hour; (2) 70% ED visits with successful contact by ACM with an ED provider; 
and  (3) 90% of patient visits have key metrics recorded by the ACM in the EMR (ED disposition, type of ED 
staff contacted, primary care team updated).  We will test each of these three outcomes independently. 
Adjusting for multiple comparisons, we want alpha 0.015 (0.05/3) and beta 0.2. With an anticipated sample 
size of 1750, we anticipate having the power to test these three adherence outcomes. We will also anticipate 
having the power to do a secondary analysis examining adherence outcomes among the residents who are a 
racial or ethnic minority (i.e. are not white, non-Hispanic) (expected N=130 ED visits). 
 
Benchmark of success: We will consider this aim completed once we collected key adherence outcomes and 
established if the pilot was successful based on prespecified go no-go criteria. These data will be shared with 
Bluestone in the form of written reports and the broader public through publications and conference 
presentations. 
 
Aim 3a: We will demonstrate the feasibility of assessing clinical outcomes using pragmatic methods 
among ALC residents with ADRD.  
The primary clinical outcome will be the proportion of eligible ED visits that result in an inpatient admission 
identified by ACMs and documented in the UDA. As mentioned above, given the anticipated six month lag in 
CMS claims data, the primary and secondary clinical outcomes including  length of ED stay, 72-hour return 
visit to the ED, and 60-day rehospitalization will be obtained from the MedRIC enclave.  
 
Benchmark of success: We will consider this aim completed once we have obtained ED disposition (primary 
outcome) for all pilot participants based on the Bluestone UDA and ED disposition from the UDA (primary 
outcome) and all primary and secondary outcomes from the CMS claims for participants enrolled in months 
two to six of the study period. These data will be shared with Bluestone in the form of written reports and the 
broader public through publications and conference presentations. 
 
Exploratory analysis) We will perform an exploratory analysis assessing the effect of the PartnerED 
intervention on the primary outcome 
We  will conduct a matched cohort design to analyze the proportion of ED visits resulting in hospital admission 
among Bluestone ACO patients with ADRD receiving PartnerED compared to Bluestone FFS patients with 
ADRD who did not receive PartnerED during the study window. Will perform a patient-level analysis with ACO 
and FFS (non-ACO) patients (matched on functional and cognitive impairment, age, sex, and comorbidities) 
that accounts for facility-level effects. Although this analysis is limited due to possible spillover effects as both 
groups will be seen in the same EDs, this exploratory analysis could further clarify the effect of PartnerED on 
hospitalization. 
 
 
 
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MILESTONES 
This project has a 12-month timeline. To ensure the project milestones are reached, we will work in parallel for 
each aim (Table 3). 
 
 
 
Aim 1: Months 1-2, we will seek institutional review board (IRB) approval for both Aims, including a waiver of 
consent for embedding and implementing PartnerED. In Months 3-4, we will identify Bluestone ACO patients 
with ADRD within the EMR using ICD10 codes. We will then validate this identification strategy with a random 
medical review. 
 
Aim 2a: Months 3-4, we will identify key stakeholders (ACMs, Bluestone physicians, ALC staff, and ED staff) 
for qualitative interviews. Months 3-4, we will finalize interview guides. Months 5-6, we will conduct and 
transcribe semi-structured interviews. Months 7-9, Interviews will be analyzed for key themes. Months 7-8, we 
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will conduct surveys of Bluestone physicians and ACMs involved in PartnerED to capture AIM, IAM, and FIM 
and descriptive analyses will be performed Months 9-10. 
 
Aim 2b: Month 1-2, we will finalize intervention materials. Months 3-8, we will implement PartnerED for the 
Bluestone ACO population. Months 3-9, we will collect adherence metrics in near real-time with data transfers 
from Bluestone EMR to MedRIC. Months 10-11, we will perform analysis on implementation adherence 
metrics.  
 
Aim 3: Months 3-9, we will collect the primary outcome, proportion of ED visits in a given hospital which result 
in hospital admissions, based on UDA in near real-time with data transfers from Bluestone EMR via MedRIC. 
Months 9-12, given the anticipated 6-month delay in CMS claims data via MedRIC, we will collect the primary 
outcome and secondary outcomes, of note proportion of eligible ED visits in a given hospital with a subsequent 
hospitalization in the following 60 days will require an additional two month delay for data to mature. Months 
10-12, we will assess feasibility of collecting outcome data based on what we have obtained from the 
Bluestone EMR and CMS.  
 
Dissemination of results 
We will publish the ADRD identification strategy (aim 1), thematic analysis of semi-structured interview (2a) 
and survey results (2b) during the study period. Given the time lag, we will need to publish clinical outcome 
results and exploratory analysis (aim 3) after the study period. For major findings and program description 
manuscripts, we will target general medicine, specialty aging, emergency medicine national conferences and 
journals such as JAMA, The Journal of the American Geriatrics Society, The Journal of the American Medical 
Directors Association, The Gerontologist, and The Annals of Emergency Medicine. 
 
 
FUTURE DIRECTIONS AND NEXT STEPS 
If proven feasible and acceptable, this pilot study will directly inform the development of a full-scale, Stage IV 
effectiveness ePCT of the Partner ED intervention. This pilot encompasses only a subset of Bluestone patients 
and only is being performed during weekdays 8a-4p. If able to prove this intervention to be feasible, it could be 
expanded to the full Bluestone fee-for-service (FFS) population. It could also serve as a catalyst for funding 
expansion of case management resources for weekend and evening coverage. The goal would be to apply for 
funding as a Demonstration Project through the IMPACT Collaboratory or equivalent mechanism. 
  
 
  
 
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