Project Details - Ended
- Grant Number:R18 HS019625
- Funding Mechanism:
- AHRQ Funded Amount:$1,061,578
- Principal Investigator:
- Project Dates:9/1/2011 to 6/30/2015
- Care Setting:
- Medical Condition:
- Type of Care:
- Health Care Theme:
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.