Trial of the CarePartner Program for Improving the Quality of Transition Support (Michigan)

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Summary:

Patients hospitalized with complex chronic conditions frequently experience preventable short‐term readmissions due to inadequate transition support. Although structured discharge planning with telephone followup improves transition outcomes, these services often are unavailable or inadequate. Informal caregivers are invaluable for ensuring successful transitions, but many patients live alone or their caregiver is struggling with competing demands. Low-cost technologies have the potential to support transitions in care while providing structured assistance for informal caregivers and supplying patients’ clinical teams with information to avert health crises.

This project evaluated CarePartner, a novel intervention designed to improve the effectiveness of transition support for common chronic conditions. CarePartner includes the ability to: (1) direct tailored communication to patients via automated calls post-discharge, (2) structured feedback about the patient’s status and advice to help, (3) a Web-based proactive disease care management tool with automated alerts about potential problems, and (4) functionality for messaging between providers and patients or caregivers.

The specific aims of this project were as follows:

  • To determine whether the CarePartner model for supporting effective transitions from hospital to home improves outcomes of care, including lower readmission rates, emergency department visits, and improved patient functional status. 
  • To evaluate the impact of the intervention on process measures of transition quality and patients' medication-related self-management. 
  • To determine whether the intervention increases the quality of life and quantity of support for patients' self-care using a mixed methods approach to identify whether the services reduce caregivers’ stress and increase their disease-specific communications with the patient. 

Patients were randomized to the CarePartner intervention or usual care. Preliminary findings indicate that 72% percent of patients completed telephone assessments demonstrating the feasibility of automated telephone monitoring and self-management support for patients transitioning from hospital to home. Outcome analyses are ongoing and will be reported in the future.

Trial of the CarePartner Program for Improving the Quality of Transition Support - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology (IT) to Improve Health Care Quality (R18)
  • Grant Number: 
    R18 HS 019625
  • Project Period: 
    September 2011 – June 2014
  • AHRQ Funding Amount: 
    $364,667
  • PDF Version: 
    (PDF, 293.82 KB)

Summary: Patients hospitalized with complex chronic conditions frequently experience preventable short-term readmissions due to a lack of coordinated care and inadequate support when they transition from the hospital to the home setting. Proactive, post-discharge followup by continual patient monitoring including caregiver support to manage their health and illness can reduce patients’ rehospitalization risk and improve the quality of care during the hospital-to-home transition.

This study will evaluate the CarePartner (CP) intervention intended to improve the effectiveness of support for transitions from hospital to home for patients with common chronic conditions. The CP intervention uses low-cost health information technology (IT) and coordinated communication between patients’ informal caregivers or “CarePartners” and their clinical teams to address their needs and manage their health. Patients in the CP intervention will receive comprehensive discharge planning for managing their chronic condition and coordinating their care across transitions. They will also receive direct, tailored monitoring and communication on self-care education via regular automated telephone calls post-discharge.

A randomized, controlled trial of 380 patients will compare those with common chronic conditions receiving usual discharge planning and post-discharge support to outcomes among patients receiving the CP intervention. Patients are being recruited from the University of Michigan Health System Medicine Inpatient Service and are asked to identify up to four potential CarePartners. CP intervention patients receive automated assessment and behavior change calls, and their CarePartner receives structured feedback and advice following each assessment. Patients’ clinical teams have access to patients’ assessment results via the Web and receive automated reports about urgent health problems. Patients complete surveys at baseline, 30 days post-discharge, and 90 days post-discharge to assess measures such as health service use, health-related quality of life, self-care behaviors, and understanding of the transition process. CarePartners complete surveys at baseline and 90 days post-discharge to evaluate factors such as CarePartner burden and satisfaction with the intervention. Data on inpatient and outpatient clinic visits will be abstracted from patient medical records to assess utilization, readmission, and mortality outcomes. The primary outcome of the trial is 30-day readmission rates. Secondary outcomes include functional status, self-care, and mortality risk.

The CP intervention targets multiple stakeholders and implements an innovative and scalable IT approach to promote successful care transitions by improving the effectiveness of patients’ CarePartners, clinician followup, and self-management of health. This coordinated approach has potential to improve the quality of care and success of care transitions among patients with common chronic conditions.

Specific Aims:

  • Determine whether the CP model for supporting effective transitions from hospital to home improves outcomes of care, including lower readmission rates, emergency department visits, and improved patient functional status. (Ongoing)
  • Evaluate the impact of the intervention on process measures of transition quality and patients’ medication-related self-management. (Ongoing)
  • Determine whether the intervention increases the quality of life and quantity of support for patients’ self-care using a mixed methods approach to identify whether service reduces caregivers’ stress and increases their disease-specific communication with the patient. (Ongoing) 

2012 Activities: The project team activities for 2012 involved preparing and opening the CP trial. The data collection tools and information management systems being used to track recruitment and enrollment in the trial were developed, institutional review board approval was obtained, staff were hired and trained, and the interactive voice response system being used in the trial was developed and tested. The CP trial opened to recruitment in late 2012 and will continue through the third year of the project.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track and the project budget spending is on target.

Preliminary Impact and Findings: This project has no findings to date.

Target Population: Adults, Chronic Care*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care and self-management support.

Business Goal: Implementation and Use

* This target population is one of AHRQ’s priority populations.

Trial of the CarePartner Program for Improving the Quality of Transition Support - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology (IT) to Improve Health Care Quality (R18)
  • Grant Number: 
    R18 HS 019625
  • Project Period: 
    September 2011 - June 2014
  • AHRQ Funding Amount: 
    $364,667
  • PDF Version: 
    (PDF, 190.97 KB)

Summary: Patients hospitalized with complex chronic conditions frequently experience preventable short-term readmissions due to a lack of coordinated care and inadequate support when they transition from the hospital to the home setting. Proactive, post-discharge followup by continual patient monitoring and ensuring that patients have caregiver support to assist with managing their health and illness can reduce patients' re-hospitalization risk and improve the quality of care when transitioning from the hospital to home.

This study will evaluate the CarePartner (CP) intervention intended to improve the effectiveness of support for transitions from hospital to home for patients with common chronic conditions. The CP intervention uses low-cost health information technology (IT) and coordinated communication among patients' informal caregivers or CPs and their clinical teams to address their needs and manage their health. Patients in the CP intervention will receive comprehensive discharge planning for managing their chronic condition and coordinating their care across transitions. They will also receive direct, tailored monitoring and communication on self-care education via regular automated telephone calls post-discharge.

A randomized controlled trial of 380 patients will compare those with common chronic conditions receiving usual discharge planning and post-discharge support to outcomes among patients receiving the CP intervention. Patients will be recruited from the University of Michigan Health Center General Medicine Inpatient Service and will be asked to identify up to three CPs. CP intervention patients will receive automated assessment and behavior change calls, and their CPs will receive structured feedback and advice following each assessment. Patients' clinical teams will have access to patients' assessment results via the Web, will receive automated reports about urgent health problems, and will be able to communicate with patients and CPs using a secure Web page and a specially-designed voicemail service. Patients will complete surveys at baseline, 30-days, and 90-days post-discharge to assess measures such as health service use, health-related quality of life, self-care behaviors, and understanding of the transition process. CPs will complete surveys at baseline and 90-days post-discharge to evaluate factors such as CP burden and satisfaction with the intervention. Data on inpatient and outpatient clinic visits will be abstracted from patient medical records to assess utilization, readmission, and mortality outcomes. The primary outcome of the trial will be 30-day readmission rates. Secondary outcomes include functional status, self-care, and mortality risk.

The CP intervention targets multiple stakeholders and implements innovative IT approaches to promote successful care transitions by improving the effectiveness of patients' caregiving network, clinician followup, and patients' self-management of their health. This coordinated approach has strong potential to improve

Specific Aims:

  • Determine whether the CP model for supporting effective transitions from hospital to home improves outcomes of care, including lower readmission rates, emergency department visits, and improved patient functional status. (Upcoming)
  • Evaluate the impact of the intervention on process measures of transition quality and patients' medication-related self-management. (Upcoming)
  • Determine whether the intervention increases the quality of life and quantity of support for patients' self-care using a mixed-methods approach to identify whether service reduces caregivers' stress and increases their disease-specific communication with the patient. (Upcoming)

2011 Activities: The project is in the development phase. Activities thus far have involved hiring essential staff for project startup, receiving institutional review board approval, developing the interactive voice response (IVR) system for the CP intervention, and training project staff to use the IVR system.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are completely on track and the project budget funds are somewhat underspent because not all project staff has been hired.

Preliminary Impact and Findings: This project has no findings to date.

Target Population: Chronic Care*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Trial of the CarePartner Program for Improving the Quality of Transition Support - Final Report

Citation:
Piette J. Trial of the CarePartner Program for Improving the Quality of Transition Support - Final Report. (Prepared by the University of Michigan at Ann Arbor under Grant No. R18 HS019625). Rockville, MD: Agency for Healthcare Research and Quality, 2015. (PDF, 1.05 MB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. (Persons using assistive technology may not be able to fully access information in this report. For assistance, please contact Corey Mackison)
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