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

29 juli 2026 bijgewerkt door: Wake Forest University Health Sciences
This study investigates better ways to help people after they leave the hospital and how to involve their families in this process. The main goal is to see if adding family support to a patient-centered hospital-to-home intervention helps patients stay safely at home, spend fewer days back in the emergency room or going back into the hospital. The study team also wants to see if the family-centered approach helps improve the patient's ability to do everyday activities without feeling overwhelmed. Two approaches are being compared: one focuses just on the patient, and the other includes special strategies to better support families involved too. Family will be involved in assessing what the patient and family needs. The family-focused approach not only emphasizes the experience, health, and safety of the patient but also the experience of the family member caring for the older adult. The study also involves families in education and provides families skills-building experiences that can help with caregiving stress, problem-solving, and communicating with the healthcare team. The approach will help the family member prepare for their loved one's transition home and provide coaching with the goal of reducing the mental, physical and financial burden of providing care at home. To spread the intervention across many states, the study team will be using telephone calls, video calls, and other technologies as families prefer.

Studie Overzicht

Toestand

Werving

Conditie

Interventie / Behandeling

Gedetailleerde beschrijving

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 program 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).

Studietype

Ingrijpend

Inschrijving (Geschat)

2560

Fase

  • Niet toepasbaar

Contacten en locaties

In dit gedeelte vindt u de contactgegevens van degenen die het onderzoek uitvoeren en informatie over waar dit onderzoek wordt uitgevoerd.

Studiecontact

Studie Contact Back-up

Studie Locaties

  • Verenigde Staten
    • North Carolina
      • Bermuda Run, North Carolina, Verenigde Staten, 27006
      • High Point, North Carolina, Verenigde Staten, 27262
      • North Wilkesboro, North Carolina, Verenigde Staten, 28659
      • Winston-Salem, North Carolina, Verenigde Staten, 27157

Deelname Criteria

Onderzoekers zoeken naar mensen die aan een bepaalde beschrijving voldoen, de zogenaamde geschiktheidscriteria. Enkele voorbeelden van deze criteria zijn iemands algemene gezondheidstoestand of eerdere behandelingen.

Geschiktheidscriteria

Leeftijden die in aanmerking komen voor studie

  • Volwassen
  • Oudere volwassene

Accepteert gezonde vrijwilligers

Ja

Beschrijving

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 (< 12 on MCA)

Studie plan

Dit gedeelte bevat details van het studieplan, inclusief hoe de studie is opgezet en wat de studie meet.

Hoe is de studie opgezet?

Ontwerpdetails

  • Primair doel: Ondersteunende zorg
  • Toewijzing: Gerandomiseerd
  • Interventioneel model: Parallelle opdracht
  • Masker: Enkel

Wapens en interventies

Deelnemersgroep / Arm
Interventie / Behandeling
Actieve vergelijker: Patient Focused Strategies
An active care transition program that includes effective strategies focused on the patient.
Ander: Patient-Centered Program
Effective strategies focused on the patient such as patient needs assessment, multi-disciplinary discharge planning, discharge instructions, follow-up education, and follow-up assessments.
Experimenteel: Patient and Family Focused Strategies
An active care transition program that includes effective strategies focused on the patient plus focused family caregiver engagement and support.
Ander: Patient-Centered Program
Effective strategies focused on the patient such as patient needs assessment, multi-disciplinary discharge planning, discharge instructions, follow-up education, and follow-up assessments.
Ander: Family Caregiver Enhanced Program
Caregiver strategies such as a family caregiver needs assessment, structured education, and skill building.

Wat meet het onderzoek?

Primaire uitkomstmaten

Uitkomstmaat
Maatregel Beschrijving
Tijdsspanne
Hospital-Free Days
Tijdsspanne: Day 60
The count of days alive and outside acute care hospitals from discharge to day 60. It will be calculated using EHR and Medicare claims data to objectively capture hospital free days elements (i.e.: mortality days, inpatient days, observation stays, and ED visits).
Day 60

Secundaire uitkomstmaten

Uitkomstmaat
Maatregel Beschrijving
Tijdsspanne
Number of Hospital-Free Days
Tijdsspanne: Day 30, 90, and 180
The count of days alive and outside acute care hospitals from discharge to a specified day. It will be calculated using EHR and Medicare claims data to objectively capture hospital free days elements (i.e.: mortality days, inpatient days, observation stays, and ED visits).
Day 30, 90, and 180
Number of Patient Readmissions
Tijdsspanne: Day 30, 60, and 90
All-cause, acute care readmissions calculated as both a count and dichotomous using EHR and Medicare claims data.
Day 30, 60, and 90
Zarit Burden Interview Score
Tijdsspanne: Day 60
Caregiver burden will be measured using the 12-item Zarit Burden Interview. Scores will range from 0 to 48. Higher scores indicate greater burden.
Day 60
Zarit Burden Interview Score
Tijdsspanne: Day 30, 90, and 180
Caregiver burden will be measured using the 12-item Zarit Burden Interview. Scores will range from 0 to 48. Higher scores indicate greater burden.
Day 30, 90, and 180
PROMIS Ability to Participate in Social Roles and Activities 8-item short form (APS-SF8) Score
Tijdsspanne: Day 60
Social role function is one's ability to perform usual social roles and activities (e.g.: leisure, family). It will be measured by using the APS-SF8. Each item is scored using a 5-point Likert scale (1=Never, 5=Always). Scores are typically converted to a standardized T-score, with a mean of 50 and a standard deviation of 10.
Day 60
PROMIS Ability to Participate in Social Roles and Activities 8-item short form (APS-SF8) Score
Tijdsspanne: Day 30, 90 and 180
Social role function is one's ability to perform usual social roles and activities (e.g.: leisure, family). It will be measured by using the APS-SF8. Each item is scored using a 5-point Likert scale (1=Never, 5=Always). Scores are typically converted to a standardized T-score, with a mean of 50 and a standard deviation of 10.
Day 30, 90 and 180
Partners at Care Transitions Measure (PACT-M) - Patient Satisfaction Score
Tijdsspanne: Day 7
Patient satisfaction will be measured using the 9-item PACT-M-1. Scores will range from 9 to 45. Higher scores indicate better perception of the quality of discharge arrangements.
Day 7
Partners at Care Transitions Measure (PACT-M) - Patient Self-Efficacy Score
Tijdsspanne: Day 30
Patient self-efficacy will be measured using the 8-item PACT-M-2. Scores will range from 8 to 40. Higher scores indicate a better experience with managing care at home.
Day 30
Patient Activation Measures Score
Tijdsspanne: Day 60
Patient activation will be measured using the 13-item Patient Activation Measures. Scores will range from 0 to 100. Higher scores indicate greater knowledge, skills, and confidence for managing their health and health care.
Day 60
Preparedness for Caregiving Scale Score
Tijdsspanne: Day 7
Family caregiver preparedness will be measured using the 8-item Preparedness for Caregiving Scale. Scores will range from 0 to 32. Higher scores indicate better preparedness for the caregiving role.
Day 7
Caregiver Self-Efficacy Scale Score
Tijdsspanne: Day 30
Family caregiver self-efficacy will be measured using the 8-item Caregiver Self-Efficacy Scale. Scores will range from 8 to 80. Higher scores indicate higher self-efficacy.
Day 30
Caregiver Activation Measures Score
Tijdsspanne: Day 60
Patient activation will be measured using the 13-item Caregiver Activation Measures. Scores will range from 0 to 100. Higher scores indicate greater knowledge, skills, and confidence for managing their health and health care.
Day 60
Visit Completion Rate
Tijdsspanne: Day 14 and 30
Number of patients that completed follow-up visit
Day 14 and 30
Time to First Outpatient Follow-up
Tijdsspanne: Day 14 and 30
Number of days between discharge and first outpatient follow-up visit
Day 14 and 30
Rate of Access to Community Services - Patient
Tijdsspanne: Day 30 and 60
Number of patients that had screening and intervention assessment for unmet social needs.
Day 30 and 60
Rate of Access to Community Services - Caregiver
Tijdsspanne: Day 30 and 60
Number of caregivers that had screening and intervention assessment for unmet social needs
Day 30 and 60
Partners at Care Transitions Measures - Adverse Events Score
Tijdsspanne: Day 7 and 30
Adverse events will be measured using the 7-item Partners at Care Transitions Measures. Scores will range from 7 to 30. Higher scores indicate greater care problems and more adverse events post discharge.
Day 7 and 30
Mortality Rate
Tijdsspanne: Day 60 and 180
Count of days to date of patient death
Day 60 and 180
Montreal Cognitive Assessment 5-minute Protocol Score
Tijdsspanne: Day 0, 60, and 180
Cognitive function (attention, orientation, language, memory, and executive function) will be measured using the Montreal Cognitive Assessment 5-min protocol. Scores will range from 0 to 30. Higher scores indicate better cognitive function.
Day 0, 60, and 180

Medewerkers en onderzoekers

Hier vindt u mensen en organisaties die betrokken zijn bij dit onderzoek.

Sponsor

Wake Forest University Health Sciences

Medewerkers

Patient-Centered Outcomes Research Institute

Onderzoekers

  • Hoofdonderzoeker: Thomas Houston, MD, Wake Forest University Health Sciences

Studie record data

Deze datums volgen de voortgang van het onderzoeksdossier en de samenvatting van de ingediende resultaten bij ClinicalTrials.gov. Studieverslagen en gerapporteerde resultaten worden beoordeeld door de National Library of Medicine (NLM) om er zeker van te zijn dat ze voldoen aan specifieke kwaliteitscontrolenormen voordat ze op de openbare website worden geplaatst.

Bestudeer belangrijke data

Studie start (Werkelijk)

22 juli 2026

Primaire voltooiing (Geschat)

1 november 2031

Studie voltooiing (Geschat)

1 november 2031

Studieregistratiedata

Eerst ingediend

16 juni 2026

Eerst ingediend dat voldeed aan de QC-criteria

16 juni 2026

Eerst geplaatst (Werkelijk)

22 juni 2026

Updates van studierecords

Laatste update geplaatst (Werkelijk)

31 juli 2026

Laatste update ingediend die voldeed aan QC-criteria

29 juli 2026

Laatst geverifieerd

1 mei 2026

Meer informatie

Termen gerelateerd aan deze studie

Trefwoorden

Aanvullende relevante MeSH-voorwaarden

Andere studie-ID-nummers

  • IRB00145199
  • PLACER-2025C1-43844 (Ander subsidie-/financieringsnummer: Patient Centered Outcomes Research Institute)

Plan Individuele Deelnemersgegevens (IPD)

Bent u van plan om gegevens van individuele deelnemers (IPD) te delen?

NEE

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Bestudeert een door de Amerikaanse FDA gereguleerd geneesmiddel

Nee

Bestudeert een door de Amerikaanse FDA gereguleerd apparaatproduct

Nee

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