Home-based Transitional Telecare for Older Veterans

Home-based Team Transitional Telecare to Optimize Mobility and Physical Activity in Recently Hospitalized Older Veterans

The project focuses on supporting home care in the post-hospitalization period (Home Health Phase), and then further optimizing the older Veterans' recovery of mobility and physical activity in the transition back to the home/community (Follow-up Phase).

Study Overview

• Status: Recruiting
• Conditions: Physical Activity; Telemedicine; Mobility; Veterans Health
• Intervention / Treatment: Behavioral: Link Team

Detailed Description

Medicare-funded home care bridges gaps in the transition of patients from hospital to home; yet, it is a bridge with gaps of its own, having limited communication with both the discharging hospital physician and the receiving primary care provider and having limited knowledge of the longitudinal medical history of the patient. Once home care is completed, there is often no plan of continued support to transition the older Veteran back to optimal home/community function.

In the Home Health Phase, a VA-home care Link Team (physician, clinical pharmacist, social worker, and physical activity trainer) will provide immediate communication/coordination between the VA Ann Arbor Healthcare System (VAAAHS) and home care agencies contracted by VAAAHS. The intervention is based on a conceptual model of home care as a bridge between hospital and home, in which three interconnected domains determine short-term and long-term outcomes: medical complexity (e.g., medication management), social complexity (e.g., caregiving, environment), and functional impairment (e.g., mobility, physical activity). The VA Link Team will provide support and assessment for each domain. The team will use telemedicine technology and wearable sensors in the home to gather patient data and facilitate communication between the patient, health care providers, and the Link Team. The Follow-up Phase begins at the end of formal home care services, when the Link Team will provide patient-centered care in two ways: 1) support for the the Veteran and caregiver in the event of changes in medical condition or medications as well as social or caregiver stressors; and 2) coaching to the Veteran and the caregiver during this transition period to optimize functional mobility and physical activity.

• Study Type: Interventional
• Enrollment (Anticipated): 100
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Kristin Phillips, PharmD; Phone Number: 734-845-5564; Email: kristin.phillips@va.gov

Study Locations

• United States
  • Michigan
    • Ann Arbor, Michigan, United States, 48105
      • Recruiting
      • VA Ann Arbor Healthcare System
      • Contact: Kristin Phillips, PharmD; Phone Number: 734-845-5564; Email: kristin.phillips@va.gov

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 50 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Under VA Ann Arbor Healthcare System (VAAAHS) primary care practitioner (PCP) oversight.
• Recently discharged from inpatient hospitalization.
• Received inpatient (pre-discharge) physical therapy evaluation and have identified rehabilitation goals for care to be provided in the home.
• Identified caregiver who agrees to participate and who will be the key link if the Veteran is unable to care for himself or has memory problems.

Exclusion Criteria:

• Require highly specialized equipment or therapy (e.g. rehabilitation for spinal cord injury, prosthesis training following leg amputation).
• Have active mental health conditions (e.g. paranoia) that may interfere with program participation.
• Require strict bed rest (e.g. long-term extensive wound healing needs) or strict use of a wheelchair.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Other: Intervention; The Link Team follows up with the participants for 6 months after they discharge from the hospital

Behavioral: Link Team; A VA home care Link Team (clinical pharmacist, social worker, physical activity trainer) provides the intervention based on a conceptual model of home care as a bridge between hospital and home, in which three interconnected domains determine short-term and long-term outcomes: medical complexity (e.g., medication management), social complexity (e.g., caregiving, environment), and functional impairment (e.g., mobility, physical activity). The Link Team provides support and assessment for each domain, and will use tablet technology and wearable sensors in the home to gather patient data and facilitate communication. At the end of formal home care services, the Link Team provides patient-centered care in: 1) support for the the Veteran and caregiver in the event of changes in medical condition or medications and social or caregiver stressors; and 2) coaching to the Veteran and the caregiver during this transition period to optimize functional mobility and physical activity.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Telemedicine Encounters	Number of successful telemedicine encounters is measured for each participant.	1 year
Successful Telemedicine Encounter Rate	Percentage of successful telemedicine encounters is measured for each participant.	1 year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Remote Short Portable Performance Battery (rSPPB)	The rSPPB, based on the widely used SPPB measures of walking speed, multiple chair stands, and standing balance, will be performed with caregiver standby assist while the Veteran is viewed via the tablet camera.	(1) Baseline; (2) Up to 6 months; (3) Up to 1 year.
Wearable sensors	Physical activity will be measured over a seven day period with a research grade sensor, the activPAL3VT.	(1) Baseline; (2) Up to 6 months; (3) Up to 1 year.

Collaborators and Investigators

• Sponsor: VA Ann Arbor Healthcare System
• Collaborators: University of Michigan; Michigan Health Endowment Fund
• Investigators: Principal Investigator: Neil Alexander, MD, VA Ann Arbor Healthcare System

Publications and helpful links

General Publications

• Alexander NB, Phillips K, Wagner-Felkey J, Chan CL, Hogikyan R, Sciaky A, Cigolle C. Team VA Video Connect (VVC) to optimize mobility and physical activity in post-hospital discharge older veterans: baseline assessment. BMC Geriatr. 2021 Sep 22;21(1):502. doi: 10.1186/s12877-021-02454-w.

Study record dates

Study Major Dates

• Study Start (Actual): September 29, 2017
• Primary Completion (Anticipated): September 30, 2022
• Study Completion (Anticipated): September 30, 2022

Study Registration Dates

• First Submitted: May 17, 2019
• First Submitted That Met QC Criteria: August 2, 2019
• First Posted (Actual): August 5, 2019

Study Record Updates

• Last Update Posted (Actual): July 8, 2021
• Last Update Submitted That Met QC Criteria: July 2, 2021
• Last Verified: July 1, 2021

More Information

Terms related to this study

• Other Study ID Numbers: AWD004365

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No