CAVIA: Continuity of Ambulant Care after Admission to a Nursing Home for People with Dementia and Behavioural and Psychiatric Problems. Elderly Outpatient Clinic Amsterdam West, GGZ InGeest, Amsterdam Department of Nursing Home Medicine, Alzheimer Center VUmc Amsterdam, the Netherlands A. Bootsma-van der Wiel, L. D. Van Mierlo, F.J.M. Meiland, R.M. Dröes, M.Stek Correspondence: Background The presence of behavioural and psychiatric problems in community dwelling people with dementia often requires out-reaching mental health services. At the time of admission to a nursing home this type of care usually is discontinued and replaced by nursing home care. Disontinuity of care and incomplete transfer of relevant information can negatively impact the wellbeing of the person with dementia and his informal caregiver. Expected Results We expect that this continuity of ambulant care will help to detect changes in mental health status and problems in provision of care and that the exchange of information will improve the continuity of care for people with dementia. This may lead to an improvement of care, wellbeing and quality of life in people with dementia and their informal caregivers. Time schedule 2010; Preparation and recruitment 2011/12: Data collection 2013: End reports. Outcome measures  Changes in Well-being and Behavioural and Psychiatric Symptoms in Dementia. (Qual-AD, NPI-Q)  Changes Care needs and Carer burden (MDS, CANE)  Careplan changes after Intervention (Semi- structured interviews, reviewing careplans)  Insight in facilitators and barriers of this intervention on topics at microlevel (such as motivation of personnel), mesolevel (consequences for cooperation with other organizations) and macrolevel (finances and legislation). Research goals 1.To evaluate changes in behaviour and wellbeing of, and quality of care for, people with dementia and their informal caregivers while implementing the intervention continuity of ambulant mental health care after admission to a nursing home. 2.To investigate positive and negative aspects of the follow-up visit of the social psychiatric nurse after admission of the person with dementia in the nursing home from the perspective of people with dementia, informal caregivers and professional caregivers, and to study whether this follow- up visit influences the care plan. 3.To investigate facilitators and barriers for continuing ambulant mental health care after nursing home admission. Methods Data will be collected with standardized questionnaires, clinical assessments before and 6 weeks after nursing home admission among 30 people with dementia and their primary caregivers. Evaluation of handover information and the care plan is performed. Qualitative research is conducted using semi-structured interviews with key figures. Key figures are patients, informal caregivers, professional caregivers, managers and health care insurers. CAVIA intervention The social psychiatric nurse visits the nursing home between 5 and 7 weeks after admission. He/she makes a new assesment of mental health of both patient and primary care giver, evaluates the care plan and discusses the situation with the responsible nursing home care professional.