ABSTRACT
This chapter discusses the crucial elements of care coordination in preventing fragmentation of care for dementia patients and their families. Continuity of care and care coordination that support the patient and family through the inevitable transitions involved as the patient with dementia transitions from one setting to another – from home/outpatient settings to the emergency department (ED), admission to the hospital, and discharge back to the patient’s home or to a sub-acute facility – includes a range of opportunities to improve patient outcomes and quality of life. Solid relationships with patients and their family, communication with members across the health care team and awareness of both challenges and resources are crucial to providing excellent care.
