Comparing Two Acute Care Transition Programs for Older Adults and Their Family Caregivers

Comparing Two Acute Care Transition Programs for Older Adults and Their Family Caregivers

This study investigates better ways to help people after they leave the hospital and how to involve their families in this process. The main goal is to see if adding family support to a patient-centered hospital-to-home intervention helps patients stay safely at home, spend fewer days back in the emergency room or going back into the hospital. The study team also wants to see if the family-centered approach helps improve the patient's ability to do everyday activities without feeling overwhelmed. Two approaches are being compared: one focuses just on the patient, and the other includes special strategies to better support families involved too. Family will be involved in assessing what the patient and family needs. The family-focused approach not only emphasizes the experience, health, and safety of the patient but also the experience of the family member caring for the older adult. The study also involves families in education and provides families skills-building experiences that can help with caregiving stress, problem-solving, and communicating with the healthcare team. The approach will help the family member prepare for their loved one's transition home and provide coaching with the goal of reducing the mental, physical and financial burden of providing care at home. To spread the intervention across many states, the study team will be using telephone calls, video calls, and other technologies as families prefer.

For all patients, the transition from hospital to home is a vulnerable period, placing them at great risk for adverse events. In a landmark 2003 report on care transitions, investigators found that 19% of patients experience adverse events soon after discharge (many preventable or ameliorable) and 66% experience adverse drug events. Care transitions also impact those around the recently discharged patient - increasing the burden on family members who provide caregiving support. Without communication and engagement in care transitions, family members experience reduced preparedness for their post-discharge caregiving role, increased caregiver burden, social isolation, and reduced mental/physical well-being.

Patient-centered care transitions can be supported through evidence-based interventions. Recent knowledge generated through PCORI's Transitional Care Evidence to Action Network and other research programs has identified remaining evidence gaps. This Phased Large Award for Comparative Effectiveness Research entitled Comparing Two Acute Care Transition Programs for Older Adults and Their Family Caregivers will create new knowledge related to engaging and supporting family caregivers. After optimization in the feasibility phase, briefly, the Phase 2 comparative effectiveness trial will have the following characteristics:

Setting: 20 Acute Care Hospitals across 5 states selected for rural/urban diversity and patient characteristics Sample: Dyads: Older Adults (N = 1,200) discharged to home and their Family Caregivers (N = 1,200)

Comparators:

Comparator A is an active care transition program that includes effective strategies focused on the patient.

Comparator B includes all Comparator A active strategies, plus focused family caregiver engagement and support.

Randomization:

1:1 Dyad-level RCT stratified by rural/urban home setting and presence of patient cognitive impairment

Patient-Centered Outcomes Include: Patient remaining safely at home (60-day hospital free days), post-discharge adverse events, patient-reported outcomes (e.g.: role functioning). Also, this study extends beyond prior effectiveness research by assessing family-caregiver-reported outcomes (e.g.: caregiver burden).

Patient Inclusion Criteria:

• 65 and older
• English and Spanish speaking
• Preadmission location: community dwelling
• Distance from Hospital: Local and Distant (rural) included
• Cognitive impairment, dementia allowed
• Technology Literacy: Flexible from high to low
• EPIC readmission risk score over 12
• Discharged home

Patient Exclusion Criteria:

• Admitted from skilled nursing facility
• Discharged to skilled nursing facility
• Left Against Medical Advice (AMA)
• Planned readmission
• Died during index admission
• Caregiver unwilling to participate

Caregiver Inclusion Criteria:

• Adults 18 and older
• English and Spanish speaking
• Providing tangible support to patient
• Distance from Hospital: Local and Distant (rural) included
• Only Mild Cognitive Impairment allowed
• Able to be trained in Video Visit Technology
• Available to support post-discharge

Caregiver Exclusion Criteria:

• Has a greater than a mild cognitive impairment (< 12 on MCA)