The University of Texas at Austin, School of Nursing
Co-Designing Care Transition Support for Dementia Patients and Care Partners
Dr. Kwak is an associate professor in the School of Nursing at The University of Texas at Austin. Dr. Kwak’s research program focuses on improving access to and quality of community-based care and palliative care that is more inclusive and equitable for people living with dementia (PLWD) and their care partners (CP). Her current research includes a longitudinal study of culturally diverse PLWD and CPs on the roles of social determinants, culture, and faith in communication and decision-making. She is also conducting a pilot study to upskill community health workers in palliative and care transition support for PLWD and their CPs. Dr. Kwak is a 2021 Sojourns Scholar leader, a fellow of the Gerontological Society of America (GSA), and 2023 vice-chair for the Social Research, Policy, and Practice section of the GSA.
Dell Seton Medical Center and Ascension Seton Medical Center Austin are two hospitals of Ascension Seton, a central Texas nonprofit health care system network of 12 hospitals and 100+ clinical locations. Annually, over 1,300 people living with dementia are served at these two hospitals.
As a HCS Scholar, Dr. Kwak will partner with an interdisciplinary team at Ascension Seton to 1) adapt the community health worker-led care transition intervention to the needs and priorities of diverse stakeholders including PLWD/CP, and 2) co-design a pilot ePCT of the adapted intervention. Both goals align with Ascension Seton’s key priorities: improving access to care for all members in the community, improving the care transition experience, and reducing preventable readmission among PLWD. Several capacity building activities that Dr. Kwak and the HCS partners will undertake include: 1) Convene a patient and family council with PLWD and CP from diverse cultural, racial, and financial backgrounds to identify their care transition support priorities, and to provide end-user input to adapt the intervention; 2) Engage clinicians, frontline providers, and administrative staff at both hospital sites to identify priorities for improving the delivery of dementia care and identify how the intervention can be incorporated in their workflow; 3) Partner with health informatics teams to review existing electronic medical records structure, data, and access processes to adapt information technology tools for accurate identification of PLWDs, documentation of CP information, and identification of potential measures of pragmatic outcomes; and 4) Develop specific aims for an application to conduct a pilot ePCT.