Mending the Cracks: A Case Study in Using Technology to Assist with Transitional Care for Persons with Dementia.

Transitions between hospital and community are particularly challenging for vulnerable adults experiencing behavioural and psychological symptoms (BPSD) of dementia. Too often, miscommunication results in triggering a recurrence of disruptive behaviours leading to frustration of staff and families. As part of the implementation of Health Quality Ontario (HQO) Quality Standards, this project involved improving transitions using an electronic-based care plan on a 23-bed geriatric dementia unit in a mental health hospital. "My Dementia Careplan," is an interprofessional care plan that was developed in the electronic medical record (EMR) to enhance communication of information between healthcare providers when patients are being discharged to the community. It is written from the patient's perspective in collaboration with the family and interprofessional team. It describes strategies to manage behavioural challenges along with the standardized tools to objectively monitor progress. This care planning will help to support transition of knowledge between hospital and community.