PROJECT SUMMARY Community-dwelling persons with Alzheimer’s Disease and Alzheimer’s disease-related dementias (AD/ADRD) are more susceptible to avoidable emergency department (ED) visits and hospitalizations than individuals in institutional settings. Adult day service centers (ADCs) provide community-based care to a growing number of highly vulnerable adults with AD/ADRD. Daily assessment and serial observations by the ADC’s interdisciplinary staff support early detection of adverse changes in health status in people with chronic conditions. However, when acute changes in users’ health status occur, ADC staff who wish to provide timely notification to primary care providers (PCPs) in order to facilitate early intervention, frequently cannot do so effectively. As the number of persons with AD/ADRD is expected to triple by 2050 and most remain in the community, there is a critical need to strengthen communication of salient clinical information between ADCs and PCPs in order to reduce costly hospitalizations and ED visits. Mobile health (mhealth) interventions can improve healthcare communica- tion processes by eliminating barriers to real-time bidirectional information exchange across a variety of settings. Yet, we previously found that ADC staff relied on facsimile or voicemail message to communicate abnormal blood pressures or acute changes in users’ behavior, resulting in a delayed or non-response from the PCP. This allowed minor health issues to escalate into medical emergencies. The objective of the proposed mixed-methods sequential explanatory study, guided by the ehealth Enhanced Chronic Care Model (eCCM), is to inform the development of a future low-cost mobile application that facilitates transdisciplinary communication between ADCs and PCPs around key risk factors for poor health outcomes in ADC users with AD/ADRD. The following are the specific aims: (1) Determine health and social risk factors that are associated with ED visits and hospi- talizations among ADC users living with AD/ADRD over a one-year period; (2) Explore barriers and facilitators of meaningful communication between ADC staff and PCPs around risk factors associated with ED visits and hospitalizations in persons with AD/ADRD; (3) Identify the key domains of a future mhealth intervention that supports communication between ADCs and PCPs surrounding risk factors associated with ED visits and hos- pitalizations in persons with AD/ADRD. In Aim 3, we anchor the findings from Aims 1 and 2 within an mhealth framework to conceptually to map key domains of a future mhealth intervention that will support productive com- munication between PCPs and ADCs around risk factors for ED visits and hospitalizations in persons with AD/ADRD. This study is significant because improved communication across community-based providers can support early clinical intervention, improve standards of care, and thwart costly adverse outcomes for a highly vulnerable subset of persons with AD/ADRD. This study is innovative because it combines large-scale data on the health and social needs of persons with AD/ADRD with the perspectives of their care providers to inform the development of urgently needed pragmatic mhealth solutions that integrate care across community settings.

PROJECT NARRATIVE Inefficient communication between members of interdisciplinary healthcare teams caring for community- dwelling persons with Alzheimer’s disease and Alzheimer’s disease-related dementias (AD/ADRD) can allow minor health issues to escalate into medical emergencies resulting in increased hospitalizations, emergency department visits and significant costs to health systems. This innovative study combines state-level standardized data on the health and social risk factors driving healthcare utilization in persons with AD/ADRD with the perspectives of their multidisciplinary community-based care team, to inform the development of pragmatic mobile health (mhealth) solutions that facilitate communication between adult day service centers and primary care providers. In doing so, this study works toward national goals of reducing fragmentation in healthcare delivery, optimizing care quality and efficiency, and expanding support for people with AD/ADRD and their families.