Implementation strategies for a pharmacist-led community-based care transition program for rural older adults with dementia and their care partners

The National Institute on Aging awarded the Regents of the University of Michigan $844,638 on September 15, 2025, under the Aging Research program (CFDA 93.866) to implement and test a pharmacist-led care transition program for rural older adults with dementia.

The project adapts the Region VII Area Agency on Aging Community Care Transition Initiative (CCTI) for older adults with Alzheimer's disease and related dementias (ADRD) and their care partners. Rural older adults with ADRD commonly experience medication problems including errors and discrepancies, increased care partner burden, and unmet health and social needs following hospitalization. The adapted program, CCTI-ADRD, combines community health worker home visits with telehealth pharmacist medication review to address medication optimization, social and health-related needs, and provides referrals and follow-up.

The project has two primary aims. Aim 1 determines factors for adapting and implementing CCTI-ADRD by conducting semi-structured interviews and direct observations with key informants including individuals with ADRD, their care partners, community health workers, area agency on aging staff, and healthcare providers, then prioritizes factors using rapid qualitative analysis and the Tailored Implementation in Chronic Disease (TICD) framework. Aim 2 tests the feasibility and acceptability of implementing the adapted CCTI-ADRD.

Work is performed in Michigan through September 14, 2027. The University of Michigan passes funding to three rural area agencies on aging as sub-recipients: Region VII Area Agency on Aging (sub-award November 10, 2025), Region II Commission On Services To The Aging / Wellwise Services Area Agency On Aging (sub-award January 6, 2026), and Region IV Area Agency On Aging Inc. (sub-award January 22, 2026). Each sub-recipient participates in determining implementation factors and testing feasibility and acceptability of CCTI-ADRD in rural settings.

Abstract

Older adults living with alzheimer's disease and related dementias (ADRD) experience remarkably complex care transitions after hospitalization. Over half have medication problems (e.g., errors, discrepancies, inappropriate use), increased care partner burden, health-related (e.g., behavioral symptoms), and social needs after the care transition home. Our team has a sustained evidence-based care transition program for rural older adults, the region VII area agency on aging community care transition initiative (CCTI), including a community health worker (CHW) home visit and telehealth pharmacist medication review that addresses medication discrepancies and optimization, social and health-related needs, provides referrals and follow-up. Gaps in our knowledge of individual and organizational determinants to inform effective adaptations for rural older adults with ADRD and their care partners and successful implementation interventions appropriate for rural area agencies on aging exist. The overall objective is to identify the key factors for adapting the CCTI for rural older adults with ADRD and their care partners (i.e., CCTI-ADRD) and to test the feasibility and acceptability of implementing the adapted CCTI-ADRD. The tailored implementation in chronic disease (TICD) framework informs our aims. Aim 1: determine factors for adapting and implementing the community care transition initiative-ADRD to address medication problems, care partner burden, and health and social needs of rural older adults with ADRD and their care partners. We will conduct semi-structured interviews and direct observations with key informants (those with ADRD and their care partners, chws, area agency on aging staff, and healthcare providers) and use rapid qualitative analysis and the TICD framework to prioritize factors, critical adaptations, and implementation barriers and facilitators. With our community advisory board, comprised of older adults with ADRD and their care partners, pharmacists, chws, and area agency on aging members, we will reach a consensus on our implementation toolkit and pilot study protocol. Aim 2: test the feasibility and acceptability of implementing the community care transition initiative-ADRD in three rural area agencies on aging. Using a mixed-methods implementation pilot study, we will assess our primary outcomes of feasibility and acceptability of the implementation strategies. Secondary outcomes are implementation fidelity, medication problems addressed, care partner burden, ADRD behavioral symptoms, and community- based services provided. Direct observations, surveys, chart reviews, and semi-structured interviews with key informants will be used. We will integrate our data, create a causal pathway diagram to examine why our implementation strategies worked, and refine our toolkit. The expected outcome is our tailored implementation toolkit to be tested further in a randomized hybrid effectiveness-implementation clinical trial. We will positively impact rural older adults with ADRD and their care partners by reducing medication problems and unmet social and health needs after the care transition home.