Cognitive Rehab Transitions

The importance of improving care transitions for patients with cognitive impairment is evident. Each year, more than 5 million Americans (mostly older adults) transition from hospitals to sub-acute rehabilitation programs in nursing homes. A majority of these, both in the state of Maryland and nationally, make a second transition – from nursing home to community dwellings. Two common patient clinical characteristics that are known to complicate both post-acute outcomes and successful post-nursing home transitions are cognitive impairment and mood dysfunction (especially depression and anxiety).  Given the high base rate of impairment in both spheres, it is vital that information regarding cognition and mood be part of the “information transfer” from setting to setting.  As the AMDA report makes clear, this is not currently happening. One way to correct this problem is to identify what types of information regarding cognitive and mood functioning is needed. This project gathered, through an online survey, the information on mood and cognitive function status being ascertained and provided at discharge and/or transfer from one facility to another. Research partner Mansbach Health Tools, LLC, (BCAT Team) which supports the BCAT® assessment tool, was central to the research and analysis of the data.  

The outcome of the research and recommendations based on the findings are available in the paper "Cognitive Rehab Transitions: Findings and Recommendations."

For more information on grant projects, contact  Lesley Flaim, Program & Marketing Manager, lflaim (at)