Because their thinking problems are not accounted for in their care, 40% of Medicare beneficiaries who are admitted to hospital who have a dementia diagnosis in their medical record return within 30 days, compounding an acute care stay into a full-blown crisis for patient and family. Hospital2Home is a program that supports adults with memory loss and their caregivers during the care transition from hospital to home. This program is delivered by social workers who provide in-person and telephone follow-up, caregiver coaching and short-term care coordination for recently discharged patients.

Cognitive Solutions LLC provides program development consultation to community-based organizations to add a dementia specialty to care transitions work they may already be doing, delivered by program managers currently running this program successfully, including building sustainable funding.

The Benefits? A unique dementia care service that produces