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

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 intervention 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 (≤ 22 on MCA)