Improving Transition Outcomes Through Accessible Health IT and Caregiver Support
| Status: | Enrolling by invitation |
|---|---|
| Healthy: | No |
| Age Range: | 21 - Any |
| Updated: | 5/6/2016 |
| Start Date: | August 2012 |
| End Date: | September 2016 |
Background: Older hospitalized adults frequently experience preventable short-term
readmissions due to inadequate transition support. Although proactive telephone follow-up
improves transition outcomes, these services often are unsystematic and of low intensity.
Informal caregivers are invaluable for ensuring successful transitions, but many patients
live alone, have an in-home caregiver who is struggling with competing demands, or live at a
distance from adult children or other potential sources of support. New models are needed
for transition support that include low-cost technologies and more structured assistance for
patients' informal caregiving network, while providing patients' clinical teams with the
information they need to avert health crises.
Objectives: Consistent with NIA's goals to improve transition outcomes, we will evaluate a
novel intervention designed to improve the effectiveness of transition support for older
adults with common chronic conditions via three mechanisms of action: (a) direct tailored
communication to patients via regular automated calls post discharge, (b) support for
informal caregivers living outside of the patient's household via structured feedback about
the patient's status and advice about how they can help, and (c) support for proactive care
management including a web-based disease management tool, automated alerts about potential
problems, and the capacity for asynchronous communication with patients and their
caregivers. Specifically, the trial will determine: 1) whether the CarePartner intervention
improves patients' readmission risk and functional status; 2) the impact of the intervention
on patients' self-care behaviors and the quality of the transition process; and 3) whether
the intervention improves caregiver burden and stress levels.
readmissions due to inadequate transition support. Although proactive telephone follow-up
improves transition outcomes, these services often are unsystematic and of low intensity.
Informal caregivers are invaluable for ensuring successful transitions, but many patients
live alone, have an in-home caregiver who is struggling with competing demands, or live at a
distance from adult children or other potential sources of support. New models are needed
for transition support that include low-cost technologies and more structured assistance for
patients' informal caregiving network, while providing patients' clinical teams with the
information they need to avert health crises.
Objectives: Consistent with NIA's goals to improve transition outcomes, we will evaluate a
novel intervention designed to improve the effectiveness of transition support for older
adults with common chronic conditions via three mechanisms of action: (a) direct tailored
communication to patients via regular automated calls post discharge, (b) support for
informal caregivers living outside of the patient's household via structured feedback about
the patient's status and advice about how they can help, and (c) support for proactive care
management including a web-based disease management tool, automated alerts about potential
problems, and the capacity for asynchronous communication with patients and their
caregivers. Specifically, the trial will determine: 1) whether the CarePartner intervention
improves patients' readmission risk and functional status; 2) the impact of the intervention
on patients' self-care behaviors and the quality of the transition process; and 3) whether
the intervention improves caregiver burden and stress levels.
Methods: 846 older adults with complex chronic conditions will be identified upon admission
to two community-based acute care medical services. Patients will be asked to identify a
CarePartner (CP) living outside their household, i.e., an adult child or other social
network member willing to play an active role in their transition support and organizing
their broader network of informal caregivers. Patients will be randomized to the
intervention or usual care. Intervention patients will receive automated assessment and
behavior change calls, and their CPs will receive structured feedback and advice following
each assessment. Patients' clinical team will have access to patients' assessment results
via the web, will receive automated reports about urgent health problems, and will be able
to communicate asynchronously with patients and CPs using a secure web page and a specially
designed voicemail service. Patients will complete surveys at baseline, 30- and 90- days
post discharge; utilization data will be obtained from hospital records. CPs, other
caregivers, and clinicians will be interviewed to evaluate intervention effects on processes
of self-care support, caregiver stress and communication, and the intervention's potential
for broader implementation. The primary outcomes will be 30 day readmission rates; 2ndary
outcomes measured at 30 and 90 days include functional status, self-care behaviors, and
mortality risk.
to two community-based acute care medical services. Patients will be asked to identify a
CarePartner (CP) living outside their household, i.e., an adult child or other social
network member willing to play an active role in their transition support and organizing
their broader network of informal caregivers. Patients will be randomized to the
intervention or usual care. Intervention patients will receive automated assessment and
behavior change calls, and their CPs will receive structured feedback and advice following
each assessment. Patients' clinical team will have access to patients' assessment results
via the web, will receive automated reports about urgent health problems, and will be able
to communicate asynchronously with patients and CPs using a secure web page and a specially
designed voicemail service. Patients will complete surveys at baseline, 30- and 90- days
post discharge; utilization data will be obtained from hospital records. CPs, other
caregivers, and clinicians will be interviewed to evaluate intervention effects on processes
of self-care support, caregiver stress and communication, and the intervention's potential
for broader implementation. The primary outcomes will be 30 day readmission rates; 2ndary
outcomes measured at 30 and 90 days include functional status, self-care behaviors, and
mortality risk.
Inclusion Criteria:
- Being discharged from study site with any diagnoses that indicate a chronic condition
with a high risk of short-term readmission, for example: stroke, heart failure,
coronary artery disease, cardiac arrhythmias, chronic obstructive pulmonary disease,
peripheral vascular disease, deep venous thrombosis, pulmonary embolism, pneumonia,
diabetes, urinary tract infection, cellulitis, gastroenteritis, fevers, and other
infections
- At least 50 years of age
Exclusion Criteria:
- Serious mental illness, e.g., psychosis
- Are in hospice care
- Do not speak English
- Are unable to use a telephone
- Have a non-health system-affiliated primary care provider
- Are unable to nominate a potentially eligible CarePartner
- Are cognitively impaired as determined by a validate screener
We found this trial at
1
site
1500 E Medical Center Dr
Ann Arbor, Michigan 48109
Ann Arbor, Michigan 48109
(734) 936-4000
University of Michigan Health System The University of Michigan is home to one of the...
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