Study: NCT06079203

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Emergency Care Redesign (ECR)
Description: Care Process Redesign: Care process redesign with a shared structured worksheet for data gathering, standardized assessment and referral. Education of all providers (Physician, Nurse, and Social Work Champion) on new processes at huddles and via on-line training, smart phone-compatible animated videos, faculty meetings, e-mail and from ED champions on shift~CDS System: Alerts and new workflow to refer the dyad to social work or care manager. Continued use throughout study period and beyond~Follow up: Within 72 hours of ED visit if discharged home Social Work Champion will have a single phone call. Triadic telephone encounter to ensure understanding of discharge plan, medication management and connection to community services

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Emergency Care Redesign (ECR)
Description: Care Process Redesign: Care process redesign with a shared structured worksheet for data gathering, standardized assessment and referral. Education of all providers (Physician, Nurse, and Social Work Champion) on new processes at huddles and via on-line training, smart phone-compatible animated videos, faculty meetings, e-mail and from ED champions on shift~CDS System: Alerts and new workflow to refer the dyad to social work or care manager. Continued use throughout study period and beyond~Follow up: Within 72 hours of ED visit if discharged home Social Work Champion will have a single phone call. Triadic telephone encounter to ensure understanding of discharge plan, medication management and connection to community services

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Emergency Care Redesign (ECR)
Description: Care Process Redesign: Care process redesign with a shared structured worksheet for data gathering, standardized assessment and referral. Education of all providers (Physician, Nurse, and Social Work Champion) on new processes at huddles and via on-line training, smart phone-compatible animated videos, faculty meetings, e-mail and from ED champions on shift~CDS System: Alerts and new workflow to refer the dyad to social work or care manager. Continued use throughout study period and beyond~Follow up: Within 72 hours of ED visit if discharged home Social Work Champion will have a single phone call. Triadic telephone encounter to ensure understanding of discharge plan, medication management and connection to community services

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Emergency Care Redesign (ECR)
Description: Care Process Redesign: Care process redesign with a shared structured worksheet for data gathering, standardized assessment and referral. Education of all providers (Physician, Nurse, and Social Work Champion) on new processes at huddles and via on-line training, smart phone-compatible animated videos, faculty meetings, e-mail and from ED champions on shift~CDS System: Alerts and new workflow to refer the dyad to social work or care manager. Continued use throughout study period and beyond~Follow up: Within 72 hours of ED visit if discharged home Social Work Champion will have a single phone call. Triadic telephone encounter to ensure understanding of discharge plan, medication management and connection to community services

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Nurse-led Telephonic Care (NLTC)
Description: Telephonic support for dyad for safe ED to home care transition, and to enhance knowledge and management of AD/ADRD and co-morbid conditions. First call to dyad within 72 hours of index ED visit from Registered nurses. Each call \~30 minutes depending on needs and willingness of dyad. Calls also occur at 14 days, and at least monthly thereafter for 6 months. Dyad or nurse can initiate additional as-needed calls and coordinate care and care needs with other providers

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Nurse-led Telephonic Care (NLTC)
Description: Telephonic support for dyad for safe ED to home care transition, and to enhance knowledge and management of AD/ADRD and co-morbid conditions. First call to dyad within 72 hours of index ED visit from Registered nurses. Each call \~30 minutes depending on needs and willingness of dyad. Calls also occur at 14 days, and at least monthly thereafter for 6 months. Dyad or nurse can initiate additional as-needed calls and coordinate care and care needs with other providers

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Nurse-led Telephonic Care (NLTC)
Description: Telephonic support for dyad for safe ED to home care transition, and to enhance knowledge and management of AD/ADRD and co-morbid conditions. First call to dyad within 72 hours of index ED visit from Registered nurses. Each call \~30 minutes depending on needs and willingness of dyad. Calls also occur at 14 days, and at least monthly thereafter for 6 months. Dyad or nurse can initiate additional as-needed calls and coordinate care and care needs with other providers

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Nurse-led Telephonic Care (NLTC)
Description: Telephonic support for dyad for safe ED to home care transition, and to enhance knowledge and management of AD/ADRD and co-morbid conditions. First call to dyad within 72 hours of index ED visit from Registered nurses. Each call \~30 minutes depending on needs and willingness of dyad. Calls also occur at 14 days, and at least monthly thereafter for 6 months. Dyad or nurse can initiate additional as-needed calls and coordinate care and care needs with other providers

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Community Paramedic-led Transitions Intervention (CPTI)
Description: Community paramedics to provide coaching with dyad to improve medication management, outpatient follow up, understanding of red flags necessitating medical care. Home visit within \~5 days of index ED visit. One home visit and three telephone encounters over 30 days

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Community Paramedic-led Transitions Intervention (CPTI)
Description: Community paramedics to provide coaching with dyad to improve medication management, outpatient follow up, understanding of red flags necessitating medical care. Home visit within \~5 days of index ED visit. One home visit and three telephone encounters over 30 days

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Community Paramedic-led Transitions Intervention (CPTI)
Description: Community paramedics to provide coaching with dyad to improve medication management, outpatient follow up, understanding of red flags necessitating medical care. Home visit within \~5 days of index ED visit. One home visit and three telephone encounters over 30 days

Intervention type: BEHAVIORAL
Group type: EXPERIMENTAL
Intervention: Community Paramedic-led Transitions Intervention (CPTI)
Description: Community paramedics to provide coaching with dyad to improve medication management, outpatient follow up, understanding of red flags necessitating medical care. Home visit within \~5 days of index ED visit. One home visit and three telephone encounters over 30 days