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Abstract

It is important to understand the range of transitional care models that support people with dementia who have complex health needs. This is to avoid unnecessary hospitalisations, to maximise any benefits in care transfers and, may increase access to higher quality care and reduce the incidence of low value care. A scoping review of peer-reviewed literature was conducted to investigate and summarise nurse or allied health-led models of transitional dementia care in Australia. Nurse and allied health-led transitional care models for older people and people with dementia included models that emphasised community services, hospital avoidance, out-reach to residential care, emergency department streamlining, intensive dementia support, or a combination (n = 14). Health outcomes reported included decreased presentations, length of stay and costs in emergency departments; reduction in hospital admissions and in medication use and increase in non-pharmacological interventions. Future models of nurse or allied health-led care should emphasise the need for localised relational approaches by the transitional staff to support continuity of care as crucial aspects for behavioural and gerontological transitional care.

Keywords

dementia geriatrics transitional care patient transfer interdisciplinary communication emergency room visits patient care team

Introduction

Dementia is a significant health care issue in Australia, compounded by a growing aging population (Australian Institute of Health and Welfare, 2024). In 2023, an estimated 15 people are living with dementia per 1,000 people in Australia, with the majority living within the community (Dementia Australia, 2023). Dementia is a progressive brain disorder resulting in progressive decline (Dementia Australia, 2024), with symptoms affecting memory, speech, cognition, behaviour and mobility (Australian Institute of Health and Welfare, 2024). People with dementia receive care across settings (home, post-acute facilities, hospitals and in residential aged care (RAC)), with support needs increasing with disease progression, and care typically provided by family, healthcare workers, healthcare practitioners and paid carers (Australian Institute of Health and Welfare, 2024; Bail et al., 2018).

People with dementia are commonly admitted to hospital for circumstances other than dementia itself, however, due to dementia, often require a greater number of nursing care hours, longer length of stay and delayed discharge (Bail et al., 2013; Bail & Grealish, 2016). Compared to people without dementia, they experience higher risk of iatrogenic complications (e.g., 1.8 times higher to develop a pressure ulcer and 2.8 times higher to develop a urinary tract infection) and have more complex health needs (Bail et al., 2013). However, despite older people with complex needs (including dementia) being the largest users of beds and care within hospitals, the current hospital system is not well suited to meeting the complex needs of this population cohort (Bail et al., 2013, 2018; Yates et al., 2018).

Furthermore, dementia services in the community have been reported to be fragmented, with poor intersectoral communication (Robinson et al., 2009). Access to general practitioners in the current primary care model is difficult for people with dementia and their carers due to limited appointment time allocation and Medicare rebates (Gibson et al., 2024; Fetherstonhaugh et al., 2021). Within the acute setting, limited clinician knowledge, skills and experience in providing care for people with dementia and complex needs is a current challenge (Evripidou et al., 2019; Schneider et al., 2020; Surr et al., 2016). Poor communication within and between hospitals, community services and residential care (i.e., intersectoral) remains a challenge, contributing to sub-optimal transfer of care (Bail et al., 2009). Within residential care, inconsistent documentation (Yates et al., 2018), declining nursing staff (Rayner & Fetherstonhaugh, 2022), and poor communication between health care professionals and carers (Rayner & Fetherstonhaugh, 2022) are commonly reported challenges.

Nurse-led or allied health-led interventions are valued due to their integrated, multidisciplinary and holistic approach to care (Bail et al., 2009; Ye et al., 2024). This is in contrast to a traditional medical paradigm of curative over preventative, whereby care becomes medicalised based on symptomology (Bail et al., 2009; Ye et al., 2024). In providing care for people with dementia, nurse-led community programs have been shown to reduce stress and improve quality of life for caregivers (Ma et al., 2023; Yamakawa et al., 2022). More information is needed to understand the characteristics, descriptors and evaluation of these models. Previous literature reviews in this area include a focus on hospital discharge for people with dementia (Stockwell-Smith et al., 2018), models of home and community care services for older people (Low et al., 2011), case management/health navigators (Stretton et al., 2023), NPs in aged care (Peters et al., 2024), complex interventions for improving independent living (Ho et al., 2023), management of behavioural and psychological symptoms of dementia in the community (Trivedi et al., 2019), and effectiveness of the Severe Behaviour Response Team (Westera et al., 2020). However, these did not examine transitional models of care, nor effectiveness for people with dementia, specific to the Australian setting.

This scoping review aims to identify and summarise the literature relating to nurse or allied health-led models of transitional dementia care in Australia over the past twenty years. The overarching research question is “What are nurse or allied health-led models of transitional dementia care in Australia?”.

Materials & Method

A scoping review of peer-reviewed academic literature was conducted between July and August 2024, guided by an established methodological framework (Colquhoun et al., 2014) and was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) statement (Figure 1). The scoping review protocol was registered on Open Science Framework (Open Science Framework, 2024).

Figure 1.

PRISMA Flow Chart

The focus of this review was to investigate and summarise nurse or allied health-led models of transitional dementia care in Australia. A PICOS approach was utilised to develop the research question (Table 1). The context was focused on Australia as findings from this review were used to support the development of a framework for dementia care within the Australian Capital Territory (ACT).

Table 1.

PICOS Approach

Population	Key words
Studies including people with dementia and subtypes (Australian Institute of Health and Welfare, 2024)	Alzheimer* OR behavior* OR behaviour* OR “behavioural and psychological symptoms of dementia” OR cognition OR cognitive OR confus* OR dementia* OR memory OR neurocognit* OR “psycho-geriatric” OR psychogeriatric AND
Intervention
Services led (or predominately led) by nurses (including registered nurses and nurse practitioners) and/or allied health as per the allied health professionals Australia definition, “university qualified practitioners with specialised expertise in preventing, diagnosing and treating a range of conditions and illnesses”. (Allied Health Professionals Australia, 2023)	“Allied health” OR “allied-health” OR “cross-disciplin” OR “geriatric team” OR “health professional” OR interdisciplin* OR “inter-disciplinary” OR multiagency OR multidisciplin* OR “multi-disciplin” OR nurse OR “nurse led” OR “nurse-led” OR “nurse practitioner” OR transdisciplin OR “trans-disciplin*” AND
Comparator
N/A
Outcomes
Evaluation of nurse or allied health-led model of transitional care
Setting
Transitional or transboundary service, defined as: A collaborative approach to care coordination, access, and health improvement, involving members of the multidisciplinary team, which is cross-sectoral, and is not bound to geographic borders (Bail et al., 2009; Chief Nursing and Midwifery Office, 2023; Helms, 2022)	“Avoidable admission” OR “case management” OR “crisis intervention” OR “discharge plan*” OR “geriatric outreach” OR “hospital avoidance” OR “in-reach service” OR “integrated care” OR “intersectoral collaboration” OR “outreach service” OR “post hospital” OR “post-hospital” OR “preventable presentation” OR “preventable readmission” OR “rapid assessment” OR “rapid response” OR “residential in-reach” OR “transition of care” OR “transitional care” OR “transitional therapy” OR “transitional”

Search Strategy

An initial search of MEDLINE and CINAHL was undertaken in consultation with a Research and Information Services Librarian to ensure appropriate use of keywords and search terms. A full search strategy was then developed through the review of titles, index terms and abstracts of relevant articles identified. The search strategy included all identified key words for each database which included, MEDLINE, CINAHL, Web of Science, PsychINFO and Cochrane. These databases were selected as they included important journals across nursing and allied-health disciplines. Manual screening of reference lists of included articles was also undertaken. Studies published between 2004-2024, written in the English language, inclusive of people with dementia, based within an Australian context, peer-reviewed and including an evaluation of a nurse or allied-health-led model with clear multidisciplinary involvement; were included into the review. The search was restricted to articles published within the past twenty years to include articles most clinically relevant to current practice. All study designs were considered if they met all eligibility criteria, however, review articles were excluded.

Screening and Selection of Studies

Following the search, citations were collated using EndNote (Clarivate, Philadelphia, PA, USA) and duplicates were removed. Studies were then uploaded onto Covidence (Veritas Health Innovation), to assist in the management and organisation of study selection and screening. Following a pilot test of 21 studies between four reviewers (SI, ND, KB, RM), all titles and abstracts were screened by one reviewer (RM) for assessment against the inclusion criteria (Ghalibaf et al., 2017). Results were cross-checked by three reviewers (SI, ND, KB). If uncertainty arose regarding eligibility, the study was progressed to full-text screening. Feedback on inclusion and/or exclusion were discussed between the reviewers (SI, ND, KB, RM), with outcomes agreed upon if any deviations occurred. All four reviewers (RM, SI, ND, KB) independently completed full-text reviews against the inclusion and exclusion criteria, with two authors independently reviewing each paper at random. The process was repeated, and any deviations were collaboratively discussed with outcomes agreed upon.

Data Extraction and Presentation

Data was extracted from included papers by one reviewer (RM) into a Microsoft Excel table designed to extract data which addressed sub-research questions. Data extraction was cross-checked by three reviewers (KB, ND, SI) (McArthur et al., 2021). The data extracted included characteristics (i.e., geographical location, funding source), descriptors (i.e., inclusion criteria, age limit, participation of the multidisciplinary team), and evaluated and/or researched outcomes of the models of transitional dementia care (i.e., evaluation outcomes, challengers and enablers) (Table 2). Data were synthesised and reported using tables summarising study characteristics, model settings, and description, evaluation outcomes and quality appraisal rating. A qualitative descriptive approach was undertaken to identify supporting quotes that embeds the voices and perspectives of people experiencing the complexities of dementia support, care and services (Hall & Liebenberg, 2024).

Table 2.

Sub-research Questions

Domains	Questions
Characteristics of the models of transitional dementia care	1. Where in Australia has the model been implemented? a. Rural, regional, remote, metropolitan b. State or territory c. Size of reach (i.e., local service area, whole state, or hospital) 2. When was the model implemented and is it still current? 3. Who funds the model? 4. What is the duration of care for the service? 5. Is the model dementia specific or dementia inclusive?
Descriptors of the models of transitional dementia care	6. Is the model nurse or allied health led or both? 7. What are the inclusion criteria for patients (inclusion, exclusion, entry and exit point)? 8. Is there an aged limit for the service? 9. Which members of the multi-disciplinary team are involved? 10. What is/was the aim of the model? 11. In what setting is/was the model implemented? 12. How are services linked and handed over (e.g., from primary care to acute care)?
Evaluated and/or researched the models of transitional dementia care	13. How was the model evaluated? 14. What were the main outcomes of the evaluation? 15. What were the challenges? 16. What were the enablers? 17. Was there a dementia-specific evaluation?

Quality Appraisal

The Mixed Methods Assessment Tool (MMAT) (Hong et al., 2018) was used to evaluate the quality of the studies selected. Two authors (RM and AS) independently appraised papers with disagreements on any criteria discussed until a consensus was reached. No studies were excluded based on the quality appraisal. The results of the quality appraisal are presented using a star rating system based on the percentage of quality criteria met: 100% = five stars; 80% = four stars; 60% = three stars; 40% = two stars; and 20% = one star (Supplemental Table 1).

Results

The search and review process are outlined in the PRISMA flow diagram (Figure 1). The search resulted in identifying 512 studies. After removing duplicates (n = 99), a total of 413 studies were included for abstract and title screening. The title and abstract review identified a total of 28 studies for full-text review. Studies were primarily excluded because they were studies conducted outside of Australia or did not explicitly mention people with dementia (or confusion, behaviours, cognitive impairment, or behavioural and psychological symptoms of dementia). Following full-text review, 14 studies were included (see Figure 1).

Quality Appraisal

Seven studies received a score of five stars (Brooks et al., 2024; Clancy, 2015; Craswell et al., 2020; Dwyer, Craswell, et al., 2017; Hullick et al., 2016; Kable et al., 2015; Kwa et al., 2021), two studies received a score of four (Pond et al., 2021; Waugh, 2009), and five studies were identified to have a score of three or below (Anderson et al., 2020; Borbasi et al., 2010, 2011; Elias et al., 2021; Marsden et al., 2018). Results of the quality appraisal can be found in the Supplemental Table 1.

Study Characteristics

Included studies were published between 2009 and 2,024. The location and size of reach of the models were inconsistently reported. Models were located across New South Wales (NSW) (n = 7) (Anderson et al., 2016; Clancy, 2015; Elias et al., 2021; Hullick et al., 2016; Kable et al., 2015; Pond et al., 2021; Waugh, 2009), Queensland (QLD) (n = 5) (Borbasi et al., 2010, 2011; Craswell et al., 2020; Dwyer, Craswell, et al., 2017; Wallis et al., 2018), Victoria (VIC) (n = 1) (Kwa et al., 2021), and unknown (n = 1) (Brooks et al., 2024). Study designs were qualitative (n = 6) (Borbasi et al., 2010; Clancy, 2015; Dwyer, Craswell, et al., 2017; Elias et al., 2021; Kable et al., 2015; Waugh, 2009), quantitative (n = 3) (Hullick et al., 2016; Pond et al., 2021) and mixed-methods (n = 5) (Anderson et al., 2016; Borbasi et al., 2011; Brooks et al., 2024; Craswell et al., 2020). Four studies included only people with dementia (Anderson et al., 2016; Borbasi et al., 2010; Kable et al., 2015; Waugh, 2009) (Table 3). In two studies, dementia was not specifically stated, however, other descriptors like behaviours or cognition factors were used to describe some of the cohort (Elias et al., 2021; Pond et al., 2021). Seven studies stated that the cohort had either dementia and/or changed behaviours (Borbasi et al., 2011; Brooks et al., 2024; Clancy, 2015; Dwyer, Craswell, et al., 2017; Hullick et al., 2016; Kwa et al., 2021). When reported, the age range across studies was between 65-78 years, with the mean age being 74 or above; indicating younger onset dementia was unlikely to have been captured in these studies (Anderson et al., 2016; Craswell et al., 2017; Elias et al., 2021; Pond et al., 2021). Results of the review are presented below following three groupings: model characteristics, enabling components and barriers to model sustainability and effectiveness.

Table 3.

Characteristics of the Transitional Dementia Care Models

Author/Date	Nurse or Allied health- led	Multi-disciplinary team including allied health (Y/N)	Location	Study design	Setting	Study Population	Sample size	Quality appraisal
Anderson et al. (2016)	Nurse-led	YMedical, nursing and allied health	NSW (rural and metropolitan)	Repeated methods design and case studies	Special care unit	Patients and staff in each T-BASIS unit	Patients n = 50 (stage 1) n = 68 (stage 2) Staff n = 76	Mixed methods*
Borbasi et al. (2011)	Nurse-led	YNP, nurses, social worker, administrative assistant	QLD	Mixed methods	RAC	Staff from 20 RACs in the health service district	n = 320 (stage 1) n = 153 (stage 3)	Mixed methods**
Borbasi et al. (2010)	Nurse-led	YAs above	QLD (metropolitan)	Case studies	RAC	Case studies referred to dementia outreach service (DEMOS)	n = 3	Qualitative(No stars)
Brooks et al. (2024)	Allied health led	NMental health and dementia counsellor	National. Included five australian states (not specified)	Pilot intervention study	Combination (community to RAC)	Family carers	n = 16	Mixed methods*****
Clancy (2015)	Nurse-led	YNursing, speech pathology and social work	NSW (rural)	Focus groups	Community	Staff of the dementia outreach service	n = 20	Qualitative*****
Craswell et al. (2020)	Nurse-led	YNP candidate, GP, all levels clinical staff at RAC and ED	QLD (regional)	Descriptive analysis and a quasi-experimental study	RAC	Number of beds in a RAC	n = 300	Quantitative descriptive *****
Dwyer et al. (2017)	Nurse-led	YNPs, RAC nurses, allied health, GP	QLD (regional)	Interviews	Combination (RAC to, hospital to RAC)	Health professionals	n = 15	Qualitative*****
Elias et al. (2021)	Nurse-led	YNurses, social work, occupational therapy, physiotherapy	NSW (regional)	Case studies	Community	Referral database	n = 1116	Qualitative**
Hullick et al. (2016)	Nurse-led	YNurse, CNC, AINs, PCAs, GPs, ED staff	NSW	Controlled pre-post design	Combination (RAC to hospital to RAC)	Number of total beds in identified RACs	n = 453	Quantitative*****
Kable et al. (2015)	Nurse-led	YNurses, doctors, allied health, CNCs, RAC staff, GPs	NSW (regional)	Qualitative descriptive study	Combination (RAC to hospital to RAC)	Health professionals and RAC staff	n = 33	Qualitative*****
Kwa et al. (2021)	Nurse-led	NNurse, ED physician, geriatrician	VIC (metropolitan)	Retrospective audit	Combination (RAC to hospital to RAC)	Number of RAC beds in the hospital RIR catchment	n = 3857 (First audit)	Quantitative descriptive*****
Pond et al. (2021) Elias et al. (2021)	Nurse-led	NNP, GP	NSW	Action research	Community	GPs from 30 practices that refer patients to the DACNP and Patients	GPs: n = 57Patients: n = 77	Quantitative descriptive***
Wallis et al. (2018)	Nurse-led	YNP, nurses, emergency physician, geriatrician, allied health	QLD	Pre-post design	Acute	Patient records	n = 25,675	Quantitative non-randomised ****
Waugh (2009)	Nurse-led	YNurses, social work, occupational therapy	NSW	Case study	Community	Mery community care staff	n = 5	Qualitative****

Key * Presented using the star rating system based on the percentage of quality criteria met: 100% = five stars; 80% = four stars; 60% = three stars; 40% = two stars; and 20% = one star. 0% = no star. No studies were excluded based on the quality appraisal.

** Acronyms: nurse practitioner (NP); general practitioner (GP); residential aged care (RAC); emergency department (ED); clinical nurse (CN); endorsed enrolled nurse (EEN); assistants in nursing (AIN); clinical nurse consultant (CNC); personal care attendant (PCA).

Model Characteristics

A total of 14 models of transitional dementia care models were identified (Table 3). The majority of models were nurse-led (n = 13) (Anderson et al., 2016; Borbasi et al., 2010, 2011; Clancy, 2015; Craswell et al., 2020; Dwyer, Craswell, et al., 2017; Elias et al., 2021; Hullick et al., 2016; Kable et al., 2015; Kwa et al., 2021; Pond et al., 2021; Wallis et al., 2018; Waugh, 2009), with only one model being allied health-led (Brooks et al., 2024). Multidisciplinary involvement and composition of the team varied between models. For example, the multidisciplinary team was described as including a NP, Clinical Nurse (CN), Endorsed Enrolled Nurse (EEN), Assistants in Nursing (AIN), clinical facilitator, social worker and administrative assistant (Borbasi et al., 2010, 2011). In comparison, Clancy (2015) described the following professions as part of the multidisciplinary team: nursing, speech pathology and social work (Clancy, 2015). The multidisciplinary team, as outlined by Elias et al. (2021), described a more varied team containing nursing, social work, occupational therapy and physiotherapy. This model also integrated services from dietetics, speech pathology, clinical psychology and, where required, a health justice lawyer (Elias et al., 2021).

Models were implemented across a range of different settings, including within the community (Elias et al., 2021; Pond et al., 2021; Waugh, 2009); RAC (Borbasi et al., 2010, 2011; Clancy, 2015); acute settings (i.e., emergency department (ED), special care unit, hospital) (Anderson et al., 2016; Wallis et al., 2018) and across settings (Brooks et al., 2024; Craswell et al., 2020; Dwyer, Alison, et al., 2017; Hullick et al., 2016; Kable et al., 2015; Kwa et al., 2021) (Figure 2).

Figure 2.

The Different Settings of the Transitional Dementia Care Models

The Geriatric Flying Squad (GFS) model was a community-based model, with an aim to improve access for vulnerable, frail older people to a multidisciplinary service (Elias et al., 2021). Through reciprocal referral pathways, emergency responders (NSW Ambulance, Police and Fire and Rescue) were able to assess the individual and provide care as an alternative to a hospital admission (Elias et al., 2021). Also aligning with improving community access to health services, the Mobile Memory Clinic (MMC), provided assessment and care for a patient in their own home by an NP (Pond et al., 2021). The Dementia Monitoring Program (DMP) was another community-based model, aimed at providing a specialist service for individuals living alone with dementia (Waugh, 2009). One model that primarily provided support for the RAC was the Dementia Outreach Service (DEMOS) model (Borbasi et al., 2010, 2011). This model provided specialist support to RACs within the Metro South Health Service District of Queensland (Borbasi et al., 2010, 2011). The Residential Care Transition Model (RCTM), provided support for people with dementia and their families in the community by assisting prior to permanent residential care (Brooks et al., 2024).

Two models were positioned within the acute setting (Anderson et al., 2016; Wallis et al., 2018). The Transitional Behaviour Assessment and Intervention Service model (T-BASIS) emerged from a NSW Health commissioned review of existing CADE units (Confused and Disturbed Elderly) with an aim to provide a service between acute inpatient care and long-stay residential care (Anderson et al., 2016). The T-BASIS model delivered care both within a hospital’s special care unit and in the RACs where the patient was initially referred (Anderson et al., 2016). Coordinating care through the ED of a hospital, the Residential Aged Care and Primary Health Collaboration (CEDRiC) project is a model that facilitates response communication and collaboration between the Health Intervention Program for Seniors (HIPs) and Geriatric Emergency Department Intervention (GEDI) services (Marsden et al., 2018). The GEDI service aims to where possible, avoid hospital admission, and if not, ensure faster admission and medical management for the person with dementia (Wallis et al., 2018).

In contrast, most of the models used services that moved across settings in a bi-directional manner, from one to another (Brooks et al., 2024; Craswell et al., 2020; Dwyer, Craswell, et al., 2017; Hullick et al., 2016; Kable et al., 2015). These models primarily encouraged communication between RAC and the acute setting, with the aim of reducing avoidable hospitalisations (Craswell et al., 2020; Dwyer, Craswell, et al., 2017; Hullick et al., 2016; Kwa et al., 2021). The Residential Acute Care Service (RACS) model used a NP to provide early intervention to a deteriorating resident within the RAC, or, if admitted to hospital, to coordinate care and early discharge back to the RAC (Dwyer, Craswell, et al., 2017). The Aged Care Emergency Service (ACE) model aimed to also avoid hospital admissions of residents from the RAC by providing clinical support to nurses to provide care in situ (Hullick et al., 2016). Additionally, the Residential in Reach (RIR) model also aimed to reduce avoidable hospital admissions for acute conditions for residents of the RAC (Kwa et al., 2021).

Table 4 summarises the type, description, evaluation outcomes, and quality appraisal scores of each of the included models of transitional dementia care. The types of models varied between studies; some aimed for hospital avoidance and RAC support, and others for support in the community. The hospital avoidance and RAC support models (Borbasi et al., 2010, 2011; Craswell et al., 2020; Dwyer, Craswell, et al., 2017; Elias et al., 2021; Hullick et al., 2016; Kwa et al., 2021; Wallis et al., 2018). These models integrated collaboration between specialised health professionals, mainly NPs, with RAC nursing staff, to empower them to: manage and identify symptoms of cognitive impairment or decline (Borbasi et al., 2010, 2011; Elias et al., 2021) or, to provide early assessment or management of acute illness (Craswell et al., 2020; Dwyer, Craswell, et al., 2017; Hullick et al., 2016; Kwa et al., 2021), to avoid emergency admissions and/or identify early signs of deterioration of residents (Borbasi et al., 2010, 2011; Craswell et al., 2020; Dwyer, Craswell, et al., 2017; Elias et al., 2021; Hullick et al., 2016; Kwa et al., 2021). Duration of the service of care provided across models was inconsistently reported.

Table 4.

Summary of the Models of Transitional Dementia Care

Author, year of publication & model Name	Model Type	Model description	Evaluation Outcomes
Transitional behaviour assessment and intervention service (T-BASIS) (Anderson et al., 2016)	Intensive support for moderate to extreme behaviour change needs	Short stay special care unit for managing challenging behaviour associated with dementia. An integrated outreach teams provide multi-disciplinary assessments, develop individualised bio-psychosocial management plans for, and appropriately discharge people with significant levels of BPSD.	Patients were admitted to the T-BASIS units primarily because of BPSD. In many cases, more than one behaviour was recorded. Most patients were admitted from home (46.61%) or residential care (40.68%). The use of pro re nata (PRN) medications reduced by the time the patient was discharged and replaced almost entirely by psychosocial interventions. Overall, the program provided a net saving of AU$3.8 m during 2009-2010 financial year and showed treating patients with dementia in T-BASIS units is more cost-effective than comparable psychiatric inpatient care, provided the units can maintain the occupancy/length of stay balance
Dementia outreach service (DEMOS) (Borbasi et al., 2010)	Hospital avoidance and RAC support	The DEMOS service is a NP led, multi-disciplinary team who assess and manage residents of RACs that are experiencing cognitive deterioration because of dementia. The team work alongside facility staff to mentor them during the practical implementation of the resident’s care plan	The service contributed towards a reduction in difficult behaviours, and in reducing staff stress associated with such behaviours. Increased levels of confidence of staff when managing residents with dementia. There was a sharp decline in both presentations and admissions to emergency, due to the service circumventing possible admissions through its intervention
Residential care transition module (RCTM) (Brooks et al., 2024)	Community support to families of people with dementia moved to RAC.	An evidence-based multi-disciplinary, multi-component psychosocial intervention, to be delivered to family carers of people with dementia in the post-placement period, led by a transition counsellor	No statistically significant differences in perceived stress, grief, depression, guilt and geriatric anxiety inventory scores of careers. There were no significant differences between the two groups over time on total perceived stress scores. However, there was a statistically significant effect of time on mean support for caring scores (p = 0.009)
Dementia outreach service (DOS) (Clancy, 2015)	Community support for early-stage dementia	This service provides support to people with early-stage dementia and their carers. The service consults with medical, nursing and allied health professionals who have specialist dementia knowledge. The model was underpinned by two theories: (1) person-centred care, and (2) the need for a biopsychosocial approach	Early intervention with the client target group was credited with ameliorating greater problems, carer burden and health costs as the disease progresses. The clinical expertise of DOS staff was valued. The multidisciplinary team allowed DOS clinicians from different disciplines to share their skills and knowledge
Nurse practitioner candidates (NCP) (Craswell et al., 2020)	Hospital avoidance and RAC support	A nurse-led (NPC) service that delivers care to acutely ill older adults living in a multi-site RAC.	Most reasons for referral to the NP clustered around assessment or management of acute illness (n = 794, 44.9%) and assessment or ongoing management of chronic conditions (n = 828, 46.4%). In most cases where prescriptions or investigations such as pathology were required (n = 214), the prescription or investigation suggested to the general practitioner (GP) by the NP matched the GP request (n = 151, 70.6%). Residents transferred to the ED from the study cost less than residents from other RACs
Residential acute care service (RACS) (Dwyer, Craswell, et al., 2017)	Hospital avoidance and RAC support	A nurse-led, mobile triage service that is responsive and services public or privately operated RACs (n = 10). The team is not ‘attached’ to any one facility and consists of two fulltime equivalent NPs. This model supports the NP to intervene early and, if the resident is admitted to hospital, to facilitate early discharge back the RAC.	The NP service facilitated the RAC resident receiving quality care in a timely manner that meet the resident and/or family wishes. When primary care physicians (PCPs) were unable to attend, the ‘in reach’ approach meant the NPs were able to respond and intervene, avoided unnecessary ED presentations and facilitated timely return to the RAC. Introduction of the NP service was an effective and viable service that had positive impact on HA, with reported acceptance by residents, their families, RAC staff and PCPs. The NP model of care provides a service that is dynamic, flexible and responsive to both patient and organisational demands within a structure where such service demands were previously absent
Geriatric flying squad (GFS) (Elias et al., 2021)	Hospital avoidance and RAC and community support	To reach those who otherwise would not access health services, GFS developed an integrated multi-disciplinary model of care to include other referral networks such as NSW ambulance, police, fire and rescue	A notable increase in referrals related to cognitive decline placing a person at risk of misadventure and abuse or neglect of an older person. All respondents reported to be satisfied with the service provided and agreed GFS reduced the need for transfer to ED for that episode of care
The aged care emergency service (ACE) (Hullick et al., 2016)	Hospital avoidance and RAC support	A nurse-led service that provides telephone support to staff within RACs to care for acutely unwell residents in situ, particularly people with dementia. The service aims to avoid ED admissions through early detection of illness deterioration of residents	ED presentations were related to falls, followed by shortness of breath and respiratory illness in both the control and intervention RACs. Over time, both groups reduced length of stay (LOS) in the ED (11 min control and 45 min intervention). Hospital admissions were significantly less in the intervention RACs by ∼40% (p = 0.0012)
Transitional care services (Kable et al., 2015)	Understanding transitional experiences	Transitional care programs are designed to ensure the coordination and continuity of health care as the person with dementia transfers between different levels and types of care. This model streamlines the transitions of care	Staff described having difficulty managing people with dementia because of the lack of a specialised unit. Discharge planning staff encountered challenges with accessing post discharge services for people with dementia because of long waiting lists. Uncertainty about the referral remained active, and whether the service would be delivered, and concerns about cognitive and functional safety. Acute hospital staff described experiencing significant pressure to discharge people with dementia early and at short notice. RAC staff described people with dementia being discharged without their health issue on admission being treated and considered that in these cases, were being treated disrespectfully by acute care staff. Inadequate documentation of discharge plans from the acute care setting was reported to result in non-delivery of some planned services in the community. People with dementia and their carers were often not provided with essential information about their planned transitional care
Residential in-reach (RIR) (Kwa et al., 2021)	Hospital avoidance and RAC support	A RAC nurse/geriatrician-led in-reach service to treat acute health conditions not able to be managed by primary care, in lieu of hospital presentation	Compared to a previous, nurse/Emergency physician-led model (model 1), the nurse/geriatrician-led model (model 2) resulted in significantly fewer unplanned ED presentations, with a significant reduction in the annual rate of ED presentations from 41.9 to 37.2 per 100 RAC beds. The proportion of ED presentations admitted to hospital did not differ significantly between the 2 models. However, the proportion of ED re-presentations (i.e., with a prior presentation within 28 days) was lower in model 2 compared with model 1. There was a significant difference in the estimated cost of ED presentations per 100 RAC beds. For those ED presentations that required hospital admission, the median LOS was similar in both models and the median cost per inpatient admission did not differ significantly. However, the cost of inpatient care per 100 RAC beds was lower in model 2 [$145,607 vs $117,531]
The NP mobile memory clinic (NPMMC) (Pond et al., 2021)	Community support for dementia diagnosis	A collaborative NP-led model of care to identify, assess and manage people with early-stage dementia. The NP mobile memory clinic was developed in consultation with consumer, primary care and residential care representatives, was trialled in consenting general practices in regional areas of socioeconomic disadvantage	The NP made 19 firm diagnoses of dementia, 31 diagnoses of mild cognitive impairment (MCI) and 24 definite diagnoses of no dementia. The NP judged 68% of patients as fitting into the MCI and dementia range, whereas the Cambridge Cognition Assessment - Revised (CAMCOG-R) only classified 49% as borderline or in the dementia range. Patients and carers found the assessment process conducted by the dementia–aged care nurse practitioner (DACNP) both highly acceptable and very useful
Geriatric Emergency Department Intervention (GEDI) (Wallis et al., 2018)	Hospital avoidance, RAC support and ED streamlining	A collaborative NP-led model in collaboration with a multi-disciplinary team, this model aims to avoid hospital admission and where this is not possible, tofast-track admission and medical management	Patients who presented during the intervention periods, were more likely to be discharged after 24hours. A 1-day reduction in hospital LOS was seen pre-intervention time period and the two intervention periods. LOS in ED was shorter for intervention groups compared with pre-intervention groups. Financial modelling reported that compared to the pre-intervention period, costs per hospital admission were lower (full-intervention period = −$1469 [95% CI, $1105, $1834] and interim-intervention period = −$1018 [95% CI, $709, $1326])
Dementia Monitoring Program (DMP) (Waugh, 2009)	Community support for people living alone with dementia	The DMP commenced in August 1998 and is an innovative aged care program, providing intensive support for people who experience confusion associated with memory loss, dementia or a mental illness, who live alone or who live with someone who cannot function as a carer	Early intervention for people with dementia was seen as important as it facilitated the development of a trusting relationship if the person accepted the DMP staff. DMP staff need sophisticated skills involving ethical practice, advanced use of discretion and sensitive decision making when engaging in the complexity and uncertainty of the lives of people with dementia who lived alone and their families. Working with people with dementia living alone involves a number of challenges and complexities for workers

Other models were community focused, providing support for people living in the community with dementia and their families/carers (Brooks et al., 2024; Clancy, 2015; Elias et al., 2021). These models identified that the families and carers of people with dementia need support, especially pertaining to decisions around transitioning from home to RAC placement (Brooks et al., 2024). In addition, information about managing early-stage dementia was also given to support carers and families through access to specialist health professionals with dementia knowledge (Clancy, 2015). Similarly, transitional support was also given to staff within the acute setting and in RAC. This support aimed to streamline the admission and discharge process and improve communication between the two settings (Kable et al., 2015) and to empower staff through upskilling to enable ethical decision making when engaging in complex situations with family/carers of people with dementia (Waugh, 2009). Alternatively, the T-BASIS model provided intensive support for people with moderate to extreme behaviour change needs within a special care unit (Anderson et al., 2016). Patients admitted into the T-BASIS special care unit often displayed more than one changed behaviour, including wandering, verbal aggression, sexual disinhibition and physical aggression, typically during personal care (Anderson et al., 2016).

Enabling Components of Models of Transitional Dementia Care

Several factors which enabled models of transitional dementia care were identified as motivating for staff hence enabling for the service. These included improved patient/resident outcomes: reduction in presentations or admissions, improved confidence, knowledge and capacity of staff across settings; available specialist care with multidisciplinary team collaboration for complex cases; nurse-led models of care which are cost-effective and improve resource allocation; supporting carers; and integrating services and care. These are outlined below, with further examples verbatim from the included studies presented in Table 5.

Table 5.

Supporting Quotes From Models of Dementia Care - Enablers

Identified enablers	Supporting Quotes
Person-centred care modelled	“The adoption of the biopsychosocial approach, which includes access to medical, psychological and social expertise, is recommended for all providers of dementia care” (Clancy, 2015)“Every ward you go to in the middle of the night has one or two dementia patients and nurses are . . . Calling us telling us to chemically sedate them or hold them down because . . . They don’t know how to manage . . . If they had expert people that specialise in that area and just looked after these (patients), things would be a lot smoother”. (Kable et al., 2015)
Reduced avoidable hospital admissions	“Seeing a reduction of up to half, the fact that nearly 75% of patients were recorded as settled at discharge” (Anderson et al., 2016)“Coinciding with the introduction of the DEMOS there was a sharp decline in both presentations and admissions to the Emergency Department of the main metropolitan hospital in the health district” (Borbasi et al., 2010)“Prior to the introduction the ACE service, the intervention RAC patients were 59 % more likely to be admitted to hospital, compared to the control RACs” (Hullick et al., 2016)“A 67% increase in RIR activity and 11% reduction in the rate of ED presentations … Our study has demonstrated that following the implementation of the new model of care, there were significantly fewer patients referred elsewhere in lieu of RIR follow-up and a reduction in RIR patients experiencing unplanned ED presentations” (Kwa et al., 2021)“Mum is very distressed with any changes in her environment at this stage so the last thing I want is her taken out of that environment and put in a hospital environment, which really … and Emergency Department is not a place for a patient with her condition. So, if that can be prevented then it’s absolutely wonderful [resident family]” (Dwyer, Craswell, et al., 2017)
Improved staff confidence, knowledge and capacity	More to do with common sense, observation, knowledge of the patient, and humane nursing than standardised therapies and, in any case, are in stark contrast to the treatment patients may have received before admission to the unit, some highly costly” (Anderson et al., 2016)“The DEMOS service is achieving impressive successes both in terms of improved management of residents, in addition to improving the capacity and clinical skills of staff” (Borbasi et al., 2010)“NPs, when responding, spent time upskilling ACF staff and assisting with confirmation of the decisions they have made. NP support meant staff were more confident to keep a larger cohort of residents at home. This combination of working to full capacity, delivering optimal care and keeping residents at home contributed to ACF staff workplace satisfaction” (Dwyer et al., 2017) (RACS)
Valued specialist care with a multidisciplinary team for complex cases	“The multidisciplinary team allowed DOS clinicians from different disciplines to share their skills and knowledge, rather than each being expert in all areas … This study recommends that clinical expertise and multidisciplinary teams are foundation principles for effective models of community dementia care” (Clancy, 2015)“The hospital social workers were very nice, but … they didn’t have the same knowledge that the NP had, and the hospital social worker doesn’t go to the facilities to see what the facilities have to offer, whereas they (NP) did, so they were able to offer knowledge of that facility, with regards to … basically how much the facilities could offer and whether or not it would suit my mother’s particular condition. And the hospital social workers could not have offered the same amount of knowledge with regards to that” (Dwyer et al., 2017)“The NP model could effectively improve assessment of patients for dementia in a primary care setting… The NP was successful in the early identification of dementia, assessment, management and linking patients and carers with available support services” (Pond et al., 2021)
Cost-effective and improve resource allocation	“The financial comparisons show that treating patients with dementia in T-BASIS units is much more cost-effective than comparable psychiatric inpatient care for people with dementia …. Overall, the T-BASIS program as a whole realised a net saving of AU$3,808,509.84 during the evaluated financial year… This model demonstrates that people with complex challenging behaviours can be managed in a way that is cost-effective and importantly, humane, and it is most clinically and cost-effective when combined with a specialist outreach service” (Anderson et al., 2016)“… if we can’t contact the GP, we will offer him a fax and then we will send him a fax outlining our queries, concerns with the resident and then we will try to contact the Nurse Practitioner. So they put a note on that something is happening, if they cannot get there in an awful hurry, with 9 times of 10 they can’t. So we normally will ring up the Nurse Practitioner and they can give us some strategies over the phone” (Dwyer et al., 2017)
Carers and families supported	“[DOS] supports the carer to develop an understanding of how to support themself, as well support the person that they care for and that includes bringing in all the structure of the community and education” (Clancy, 2015)“Well, I just think being in a space where they knew exactly what you were talking about. They were talking, this is an area that is their field. They know the feelings. They know all the things that we can talk through. Thereare ways to help you, you know, deal with things in the moment” (Brooks et al., 2024)
Integrated services and care	“The strategies involved in building cohesion are included as a core activity, and the expert skills required are recognised. It is recommended that this principle and its associated skills are adopted into practice for integrating community care, particularly where distance can create isolation for rural services” (Clancy, 2015)“Prior to the reciprocal pathway, an alternate referral option was not available to those not requiring acute hospitalisation. To meet this unmet need, the NSWA Paramedics pathway evolved to include any consumer who may be experiencing a sub-acute decline, including medical or functional decline, falls, behavioural and psychological symptoms of dementia (BPSD), delirium, refusing to transfer to hospital, end of life care, carer stress and abuse of an older person” (Elias et al., 2021)“In line with the ACE service model of care, by developing relationships and opening communication between the intervention RACs and ED, there was a clearer understanding of the purpose of the transfer and what needed to be done by the ED … The ACE service has continued to evolve from this pilot to now cover eight EDs and 120 RACs. The local Primary Health Network has accountability for supporting integrated care. Without a shared accountability between acute care hospitals, RACs and older people and their families, management of acutely unwell residents can be less than ideal” (Hullick et al., 2016)

^aAcronyms: dementia outreach service (DEMOS); the aged care emergency service (ACE); residential in reach (RIR); aged care facility (ACF); nurse practitioner (NP); residential aged care facility (RAC); emergency department (ED); dementia outreach service (DOS), transitional behaviour assessment and intervention service (T-BASIS); general practitioner (GP).

Patient/resident-centred care was at the forefront of models (Anderson et al., 2016; Clancy, 2015; Craswell et al., 2020; Kable et al., 2015; Waugh, 2009). Applying this lens improved the quality of life of people with dementia and/or with challenging behaviours as it highlighted the person rather than a medical diagnosis. Typically guided and supported by an NP, alternative case management, and strategies that employed psychosocial principles rather than a reliance on pharmaceutical interventions were suggested and implemented in collaboration with the RAC nursing and residential care staff (Anderson et al., 2016; Clancy, 2015; Craswell et al., 2020; Kable et al., 2015; Waugh, 2009). The DEMOS model highlighted this underpinning philosophy as using, “ minimal medication with maximal nursing interventions” (Borbasi et al., 2011). The NPs of the T-BASIS service encouraged the implementation of psychosocial interventions by RAC nursing staff, resulting in improved quality of care for residents. Without the T-BASIS service, 40.7% of nurses stated they would have used sedation to manage patients, 18.5% would have asked for a GP medical review, 7.4% would have sent the patient to ED, another 7.4% would have referred the patient to local mental health team and 7.4% would have used one-to-one special care (Anderson et al., 2016).

A reduction in the number of avoidable hospital admissions were reported by services which integrated a NP to coordinate supportive care and guide clinical and behaviour management plans for residents/patients across RAC and acute settings (Anderson et al., 2016; Borbasi et al., 2010, 2011; Craswell et al., 2020; Hullick et al., 2016; Kwa et al., 2021). While the hospitalisation rates of residents from RACs varied between models, the involvement of a NP consistently resulted in fewer admissions (Anderson et al., 2016; Borbasi et al., 2010, 2011; Craswell et al., 2020; Hullick et al., 2016; Kwa et al., 2021). For example Craswell et al. (2020) reported that 61.8% of transfers to the emergency department occurred when the NP was not on duty, compared with 21.5% when the NP was present (Craswell et al., 2020). Avoiding unnecessary hospital admissions not only ensured the continuity of care for the residents within a familiar environment but was also highly valued by carers and family members.

Models that invested NP time to provide training to staff across different settings resulted in an increase in confidence, knowledge and capacity to provide care for residents and people with dementia and/or with changed behaviours (Anderson et al., 2016; Borbasi et al., 2010, 2011; Clancy, 2015; Dwyer, Craswell, et al., 2017; Hullick et al., 2016; Kable et al., 2015; Pond et al., 2021; Wallis et al., 2018). This in turn also contributed to avoiding hospital admissions of residents as RAC nursing staff were better equipped to identify, treat and manage the complex needs of residents (Anderson et al., 2016; Craswell et al., 2020; Elias et al., 2021; Kwa et al., 2021). NPs provided reassurance and guidance about the severity of symptoms of residents in relation to whether immediate admission to hospital was required (Dwyer, Craswell, et al., 2017). This form of support from NPs to RAC nursing staff was highly valued, considering limited access to GPs (Clancy, 2015; Dwyer, Craswell, et al., 2017).

It was reported that the complexity of care for people with dementia and/or with changed behaviours was often exacerbated by multiple co-morbidities (Anderson et al., 2016). Thus, the need for specialist gerontological care was not only recommended but commonly emphasised in many of the studies (Anderson et al., 2016; Clancy, 2015; Dwyer, Craswell, et al., 2017; Elias et al., 2021). For example, the T-BASIS study reported that residents are “often admitted to the units because the resources of their RAC are insufficient to provide appropriate management where they are” (Anderson et al., 2016). In most studies, this specialist care was NP-led, who has the knowledge and expertise to fulfil this care need with support from a multidisciplinary team (Anderson et al., 2016; Clancy, 2015; Dwyer, Craswell, et al., 2017; Elias et al., 2021). Confirming the expertise of the NP, it was recognised and reported that the identification, diagnosis and care management plan devised were similar to that of the residing GP at the RAC (Craswell et al., 2020). This was further supported by findings from the NPMMC model which indicated that the NP had the clinical knowledge and expertise to effectively identify, assess and manage people with dementia (Pond et al., 2021).

Additionally, it was reported that nurse-led models of care have the potential to be more cost-effective because hospital admissions, re-admissions and hospital length of stays are reduced, compared to non-nurse-led models (Anderson et al., 2016; Craswell et al., 2020). Dwyer et al. (2017) highlighted that the NP intervention kept residents at home and saved other healthcare services such as ambulance, emergency and inpatient care time. The T-BASIS model evaluation reported a net saving of AU$3,808,509.84 (Anderson et al., 2016), while the RIR model reported significant cost savings, with a 9% reduction in the estimated cost of emergency presentations and a 19% reduction in actual inpatient costs (Kwa et al., 2021). The cost-effectiveness of avoidable admissions, in addition to improved quality of care, was also emphasised.

Collaboration and integration of services and care across all settings (i.e., home, community and acute) was recommended, especially for rural and remote health districts (Clancy, 2015; Dwyer, Craswell, et al., 2017; Elias et al., 2021; Hullick et al., 2016; Kable et al., 2015; Kwa et al., 2021; Waugh, 2009). NPs were identified as playing a crucial role in ensuring an integrated system of care and were commonly described as being the communication ‘bridge’ between settings and services” (Dwyer, Craswell, et al., 2017).

Barriers to Model Sustainability and Effectiveness

Several barriers were also identified from the included studies that challenged the effectiveness and sustainability of models (Table 6). These barriers included restrictions to the NPs’ ability to provide care within a health district (Anderson et al., 2016; Clancy, 2015; Dwyer, Craswell, et al., 2017; Pond et al., 2021) and the need for increased nursing and residential staff with specialised skills in dementia care (Anderson et al., 2016; Craswell et al., 2020).

Table 6.

Supporting Quotes From Models of Dementia Care - Barriers

Identified barriers	Supporting Quotes
NPs ability to provide care within a health district	“The NPs in this study will attend to around 240 residents with around 1100 occasions of service annually … Unique to this regional service is that the NPs respond to up to ten ACFs across several towns, which means they can spend a lot of their workday in the car travelling. For up to ninety percent of the referrals, the NPs reported traveling for 30 min or more to attend the resident … Elements of distance, funding and professional restrictions all limited the NPs ability to work to their full potential, having a negative impact on the HA RACS service delivery and patient outcomes ” (Dwyer et al., 2017)“Although both NPs were endorsed, each encountered difficulty in securing MBS and/or PBS authorisation, which restricted their capacity to order diagnostic investigations, prescribe medications or initiate referrals. At the time, there were few NPs with full MBS and PBS authorisation and relevant expertise in aged care in the region … One of the most significant barriers to the DACNP’s scope of practice was the fact that both incumbents had difficulties securing PBS and MBS authorisation, limiting investigation, prescribing and referral” (Pond et al., 2021)
Need for increased nursing and residential staff with specialised skills in dementia care	Most transfers from the study ACF occurred outside NPC working hours, for residents the NPC or GP had not seen in the previous 48 h, in addition, few referrals of residents to the NPC came from the care staff. This points to previously reported problem with the identification of deterioration of residents by ACF staff …. The dilution of qualified clinical staff in ACFs with nursing assistants increases clinical staff reliance on an unskilled workforce to report signs of deterioration in residents” (Craswell et al., 2020)“The practice of transferring unwell PWD from hospital to low-care RACs which have very high resident-staff ratios and limited access to qualified nurses, particularly out of hours, the scene is set for increased patient risk of an adverse event” (Kable et al., 2015)

Identified barriers

Supporting Quotes

NPs ability to provide care within a health district

“The NPs in this study will attend to around 240 residents with around 1100 occasions of service annually … Unique to this regional service is that the NPs respond to up to ten ACFs across several towns, which means they can spend a lot of their workday in the car travelling. For up to ninety percent of the referrals, the NPs reported traveling for 30 min or more to attend the resident … Elements of distance, funding and professional restrictions all limited the NPs ability to work to their full potential, having a negative impact on the HA RACS service delivery and patient outcomes ” (Dwyer et al., 2017)“Although both NPs were endorsed, each encountered difficulty in securing MBS and/or PBS authorisation, which restricted their capacity to order diagnostic investigations, prescribe medications or initiate referrals. At the time, there were few NPs with full MBS and PBS authorisation and relevant expertise in aged care in the region … One of the most significant barriers to the DACNP’s scope of practice was the fact that both incumbents had difficulties securing PBS and MBS authorisation, limiting investigation, prescribing and referral” (Pond et al., 2021)

Need for increased nursing and residential staff with specialised skills in dementia care

Most transfers from the study ACF occurred outside NPC working hours, for residents the NPC or GP had not seen in the previous 48 h, in addition, few referrals of residents to the NPC came from the care staff. This points to previously reported problem with the identification of deterioration of residents by ACF staff …. The dilution of qualified clinical staff in ACFs with nursing assistants increases clinical staff reliance on an unskilled workforce to report signs of deterioration in residents” (Craswell et al., 2020)“The practice of transferring unwell PWD from hospital to low-care RACs which have very high resident-staff ratios and limited access to qualified nurses, particularly out of hours, the scene is set for increased patient risk of an adverse event” (Kable et al., 2015)

^ahospital avoidance (HA); nurse practitioner (NP); residential aged care (RAC); medicare benefits scheme (MBS); pharmaceutical benefits scheme (PBS); dementia aged care nurse practitioner (DACNP).

Studies identified that due to a high case load associated with providing care within the community and in RACs across multiple health districts or over large geographical distances, NPs often reported conflicting priorities that were exacerbated by time lost due to travel (Anderson et al., 2016; Clancy, 2015; Dwyer, Craswell, et al., 2017). While GPs, nursing and residential staff endorsed the role of NPs in providing care for residents, professional restrictions were also noted as barriers to care and included: ability to prescribe medication, services not eligible for Medicare rebates and tensions in determining the NP is working to their full scope of practice (Dwyer, Craswell, et al., 2017; Pond et al., 2021).

Additionally, another barrier was current nursing and residential staff knowledge, skills and workload capacity to manage residents with dementia and/or with challenging behaviours (Anderson et al., 2016; Craswell et al., 2020). While upskilling initiatives were embedded within most models, it was evident that without this specialised gerontological knowledge, there is a high potential for the deterioration of resident care and outcomes, as high-risk symptoms and signs are not being identified promptly. To provide care to people with dementia and/or with challenging behaviours, a high demand is placed on RAC nursing and residential care staff (Anderson et al., 2016). Currently, the lack of nurses working with RACs that have specialised skills is limited, which also has consequential impacts within the acute setting (Kable et al., 2015). The models delivering in-reach to RACs recognised the knowledge and competency gaps in the sector, and responded with a comprehensive approach to both serve the clinical needs of residents as well as upskill onsite staff by modelling care practices and providing education in teachable moments.

Discussion

The review found published evidence of a range of transitional nurse-led models and a single allied-health-led model in Australia, including community support, hospital avoidance (which often included a form of residential aged care in-reach), and intensive support by way of standalone units. The studies were predominantly qualitative evaluations, with some quantitative measures that were not consistent and, therefore, not comparable.

The community support approach ranged from home visits by a NP for dementia diagnosis to follow-up support for carers when a person with dementia has transitioned to residential aged care. Diagnosis of dementia is a key gap in service provision (Cappetta et al., 2020), and effective pathways to develop NPs are needed to enhance care delivery for this population (Peters et al., 2024). The finding that trainee NPs can fill this gap while working towards endorsement warrants further implementation investigation. NPs/Advanced Practice nurse-led models of care have also shown promise internationally (Callaghan, 2008; Naylor & Kurtzman, 2010). The in-reach service approach is common in multiple hospital models, with a recent survey of geriatric medicine departments showing that 59% of those surveyed have such a service to RAC, but that one of the most frequent suggestions to manage gaps is to increase staff numbers and policy for sufficient reach and impact of in-reach/outreach care (Azarias et al., 2024). Intensive support was only reported in one identified model (Anderson et al., 2016). Purpose-built behavioural management units are highlighted as a need in the recent geriatric survey (Azarias et al., 2024).

Underlying all the models is a response to gaps in workforce related to specialised gerontological knowledge and pathways to support clinicians to choose aged care as a career (Peters et al., 2024; Traynor et al., 2024). The lack of clinical functionality of residential aged care has been problematic for some time as highlighted by the Australian Royal Commission into Aged Care Quality and Safety (2021), and the resultant changes to bolster the workforce, policies and practices, and sustain the retention of high quality clinicians in residential care will take time (Traynor et al., 2024). Hospitals, health services and governments have long recognised that hospital avoidance is an important service pathway that can be served by in-reach to residential aged care in order to positively affect hospital length of stays (Australian Institute of Health and Welfare, 2024), as demonstrated by the high rates of out-reach services from geriatric departments (Azarias et al., 2024).

In a 2,023 review of complex care models for older people internationally, most included holistic assessment (94%) and care planning (90%), half involved multidisciplinary care (54%), most were delivered mainly by primary care teams without geriatricians (30%) (Ho et al., 2023). Ho highlights that nurses were the most frequent care coordinators, and this is reinforced by our review. Complex interventions increased the likelihood of living at home, reduced mortality, enhanced cognitive function, and improved instrumental activities of daily living (Ho et al., 2023). This highlights the need for transitional models to provide complex interventions to sustain independence and delay acute and residential interventions.

The modelling of care behaviours by experienced staff with clinical credibility, additional staff to improve ratios in order to add responsiveness, and the concomitant support network for nurses, were crucial to success in a number of programs in this review Borbasi et al. (2011); Clancy (2015); Dwyer, Craswell, et al., 2017; Elias et al. (2021); Hullick et al. (2016); Kwa et al. (2021); Westera et al. (2020) rapid evidence assessment examined localised rapid response services targeting people with changed behaviours related to dementia, highlighting the Severe Behaviour Response Team (SRBT) as a large-scale intervention (Westera et al., 2020). Operational attributes key to responding were: clearly defined parameters and processes; provision of clinical expertise and knowledge translation activities; person-centred philosophy; relationship-oriented approach to stakeholders (Westera et al., 2020). Differences between large, centeralised responses like SRBT and local programs that build community and workforces show warrants further study. Clinician leadership of residential care staff can leave staff feeling empowered and supported as a primary outcome, even where the behaviours remain ‘unsolved’ (Anderson et al., 2020). Specialised training and education are key components in delivering effective transboundary transitional care in previous studies (Naylor & Kurtzman, 2010, Callaghan, 2008; Boltz, 2015; Renehan, 2013); this review emphasises the localised and relational nature of transitional support services as key to successful outcomes in staff education as well as resident care. Future models or embellishments should emphasise these relational approaches in conjunction with continuity of care as crucial aspects for behavioural and gerontological transitional care.

A key issue revealed in the review was the need to decrease the separation of community and acute services, with nurses frequently providing a bridge between services and a rapid response to prevent deterioration of the older person and decrease magnitude of health issues. These transitional nursing (or allied health) roles are arguably particularly important in a climate of nurse dissatisfaction with role and burnout, and ongoing calls for maximising nursing capacity (Peters et al., 2024) and recognition that nurses are often not able to work to their full scope of practice. In particular, endorsed NPs, can encounter barriers in ordering subsided diagnostic testing and prescription medication. These are important avenues for investigation and development to ensure models of care are maximised for greatest impact on patient experiences.

It is also important to note often registered nurses in RAC are unable to work to their full scope of practice due to RAC workforce training, skills and capacity Royal Commission into Aged Care Quality and Safety (2021). It was only after the Australian Royal Commission that dementia care training became mandatory for personal care workers. When RAC staff are underperforming, nurses must fill these gaps, limiting their capacity to focus on higher-level care. Additionally, staffing numbers and ratios required a Royal Commission to even be recognised as key to adequately respond to complex behavioural care needs Royal Commission into Aged Care Quality and Safety (2021). While the increase in staffing ratios have likely improved since the studies in this review were conducted, the models of care reported in this review highlight the variation between services and the uneven nature of advancement in skills, knowledge and capacity across sectors and locales. It is important to recognise that both quality of knowledge and skills as well as quantity of staffing will impact older person health outcomes. The studies in this review highlighted the responsiveness of transitional gerontological NP roles to adapt to service and workforce needs in situ.

There are known alternative models that were not revealed in the review. These include nurse navigators, which are well established in managing complex care such as people with cancer and transitioning to self-management, so there may be scope for pivoting to dementia and gerontological care (Byrne et al., 2024). GP-led models of collaborative dementia care management have also been found to be associated with fewer BPSD symptoms, better mental health and lower caregiver burden (Byrne et al., 2024). Advanced practice nurses are found to support the management of geriatric conditions all over the world, including cognitive decline and delaying or averting the development of disability (Fougère et al., 2018). These models may also provide important insights for further research and development.

The strength of this review is that it provides an overview of the last twenty years of peer-reviewed literature related to transitional care in Australia, inclusive of people with dementia. Limitations included identification of keywords due to the variation in nomenclature and unique nature of the models. Many papers focused on gerontological populations without explicit mentions of dementia, behaviours or cognition, though likely included conditions with cognitive impairment. This invisibility of dementia and changed behaviours within the gerontological models may be partly due to the difficulty in accessing accurate and reliable diagnosis and documentation of dementia (Cummings et al., 2011).

Conclusion

Nurse and allied health-led transitional care models for older people and people with dementia were any one of (or a combination of) community bolstering, hospital avoidance and in-reach to residential care, or intensive dementia support focused. These models were associated with some improved health outcomes including decreased presentations, length of stay and cost in emergency departments, reduction in hospital admissions, reduction in medication use, increase in non-pharmacological interventions, decrease in carer time burden, and increase in documented diagnosis of dementia. Staff impacts included gains in confidence, knowledge and capacity of staff across settings and satisfaction with care models trialled. Key enablers of transitional models were effective integration of multidisciplinary team collaboration, and support for carers. Key barriers included restrictions to nurse (and in particular NP) scope of practice, and the need for more specialised dementia care nurses and residential staff. Integration of specialised NPs can provide further support in upskilling and educating ‘insitu’ staff and thus contributing to improved confidence, skills and knowledge in dementia care provision. However, it is worth noting that currently within Australia, there is a small pool of highly skilled dementia care nurse practitioners and ongoing issues with recruitment and retention within these roles. Further support for multidisciplinary workforce mix in dementia services, and education for all clinicians regarding collaborative skills and training were implicated by this review. Future models or embellishments of nurse or allied health-led care should emphasise the need for localised relational approaches by the transitional staff to support continuity of care as crucial aspects for behavioural and gerontological transitional care.

Relevance for Clinical Practice

This review found that nurse-led in-reach services to aged care, emergency department streamlining for people experiencing changed behaviours, and intensive behaviour support units were associated with positive health and service outcomes for dementia care. The clinical credibility and expertise of the nurse or allied health professional leading the services were found to be important for providing relational approaches to health staff education as well as continuity of care for residents/patients.

Supplemental Material

Supplemental material - Nurse or Allied Health-Led Models of Transitional Dementia Care in Australia: A Scoping Review

Supplemental material for Nurse or Allied Health-Led Models of Transitional Dementia Care in Australia: A Scoping Review by Rebecca Mete, Aisling Smyth, Nathan D’cunha, Diane Gibson, Stephen Isbel and Kasia Bail in Dementia

Footnotes

Acknowledgements

The papers authors appreciate the members of the Centre of Ageing Research and Translation and the Dementia Health Experts Network feedback and contributions to the development of this work. Acknowledging the evolving nature of language, the authors have endeavoured to use respectful language throughout this report as guided by the Dementia Australia Language Guidelines (Dementia Australia, 2023). As a scoping review, oftentimes the language of the source material was used which may not be consistent with the current guidelines. The University of Canberra acknowledges the Ngunnawal people, traditional custodians of the lands where Bruce Campus is situated. We wish to acknowledge and respect their continuing culture and the contribution they make to the life of Canberra and the region. We also acknowledge all other First Nations Peoples on whose lands this report was prepared.

ORCID iDs

Rebecca Mete

Aisling Smyth

Nathan D’cunha

Diane Gibson

Stephen Isbel

Kasia Bail

Author Contributions

Rebecca Mete: Investigation, writing (original draft), methodology, writing (review & editing), formal analysis and project administration.

Aisling Smyth: Investigation, writing (review & editing) and formal analysis.

Dr. Nathan D’Cunha: Investigation, methodology, writing (review & editing) and formal analysis.

Diane GIBSON: Writing (review & editing).

Stephen Isbel: Investigation, methodology, writing (review & editing) and formal analysis.

Kasia Bail: Conceptualization, funding acquisition, methodology, writing (review & editing) and supervision.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This report about nurse or allied health-led models of transboundary dementia care in Australia was partially funded by the ACT Health Directorate. This is a second of two reports commissioned by ACT Health Directorate from Centre for Ageing Research and Translation related to dementia, with the first report relating to health professional interviews and recommendations.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Rebecca Mete, Rebecca is an academic at the University of Canberra College and is an Accredited Practising Dietitian. Her research interests include nutrition education, vegetarian diets, women’s health and the role of nutrition in ageing.

Aisling Smyth, Dr. Aisling (Ash) Smyth is a Registered Nurse and Associate Professor of Nursing at the School of Nursing and Midwifery, University of Canberra. Aislings work is focused on optimising outcomes for Older Adults through preventative care, improved gerontological workforce and digital interventions.

Nathan D’Cunha is an Associate Professor, ACT Health Research and Innovation Fellow focused on dementia rehabilitation, and the Dementia and Cognition theme lead in the Centre for Ageing Research and Translation. Nathan’s work is focused on people with dementia and their care partners, spanning reablement and rehabilitation interventions for people living in the community and residential care. He has contributed to work to improve models of care for people with young onset dementia, and leads projects focused on intergenerational programs in residential aged care which brings together older and younger people. He is the Australian Association of Gerontology ACT Division Chair and is Co-deputy Chair of the ACT Ministerial Advisory Council on Ageing. Nathan has previously held positions working in residential care and pathology.

Diane Gibson, Professor Gibson is a Distinguished Professor (Health and Ageing) at the University of Canberra. Her strong interest in the policy/research interface has characterised her work across the sectors of health, ageing, gender and social policy. Professor Gibson is nationally and internationally recognised for her research on ageing and aged care. Her current work research focus is on the oldest old, rights and older persons, and aged care policy.

Stephen Isbe, Professor Isbel is an occupational therapy academic with research interests in allied health care, post stroke rehabilitation, dementia care, aged care and occupational therapy education. He teaches into the Master and Bachelor of Occupational Therapy courses at the University of Canberra and is the Deputy Director of the Centre for Ageing Research and Translation.

Kasia Bail, Dr. Bail’s primary interest is to improve care health delivery for older people with complex health needs. Her nursing career has always combined both research and clinical roles, with experience primarily in general medical and acute palliative care. Her peer reviewed publications are well-cited, and range in topics that include digital health systems, older people, hospitals, aged care, nurse practitioners, prognosis communication, policy analysis, dementia care, nurse care rationing, and the costs of nurse-sensitive outcomes.

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