Evaluating the Further Enabling Care at Home (FECH) post-discharge program as a way to support carers of older hospital patients

The Further Enabling Care at Home (FECH) program is a post-discharge telephone caregiving support program for carers of older medical patients discharged home from hospital. There are three manuals used in the support of this program: a FECH training manual for preparing those who will deliver the intervention (FECH nurses), a FECH implementation manual to support the FECH Nurses in their role, and a resource manual (tailored to each of the two states involved) that documents resources available to provide support for carers, including resources that can help them learn more about the care recipient's health condition (eg, Carers WA, Alzheimers WA, Motor Neurone Disease Association). Training is to be delivered to FECH Nurses over three days and will include: (a) determining the extent and type of discharge information provided to the carer, any clarification needed or additional information required (delivered by a nurse with an acute care background); (b) using the Carer Support Needs Assessment Tool (CSNAT) approach(1) (delivered by a nurse with expertise in carer support plus a palliative care researcher who has trialled this tool in palliative home care); (c) embedding a problem-solving approach for carers so that it can be used in the longer term, after the program has ended (delivered by a psychologist with special expertise in this area); and (d) types of resources that may be helpful to carers (delivered by a nurse with a background in carer support). Attendance lists will be kept to document FECH Nurse training attendance and FECH Nurses will be required to attest to their having completed the required on-line training prior to the face-to-face training. The CSNAT approach is used as part of the FECH program, to help carers identify their own needs, and the FECH Nurses undertake CSNAT training online at http://csnat.org/training/as well as during the training described above. The online CSNAT training also provides access to an online CSNAT toolkit. The FECH program is a telephone based, post-hospital-discharge, hospital outreach protocol implemented for individual carers by one or more specially prepared FECH nurses with acute gerontological nursing care experience and substantial knowledge on how to navigate the home care ‘system’ and home caregiving resources. Phone calls (therapeutic contacts) are supplemented with email and mail correspondence, as agreed with the carer, when resources or information are provided by the nurse, rather than accessed directly by the carer from other sources. The program will be delivered over 6 months, to embed the processes of carers: (a) reflecting upon the current caregiving situation, (b) identifying and prioritising new or ongoing support needs, and (c) implementing a problem-solving approach to address these support needs. The intention is that carers will then have the problem-solving skills to continue without support from the FECH nurse. The FECH program involves six contacts by the FECH nurse with the carer over the six months after the care recipient’s discharge home from hospital (at 1 and 2 weeks after discharge, then at 1, 2, 4, and 6 months post discharge). During Contact 1, the FECH nurse first elicits the carer’s understanding of information provided to them, at the time of the discharge, by the hospital. This occurs during a brief telephone interview lasting, on average, 15 minutes. If the carer demonstrates insufficient understanding of discharge information to form the basis for caregiving, as determined by the nurse when this is explored during the interview, the FECH nurse guides the carer to access the information required. The Carer Support Needs Assessment Tool (CSNAT) (1) is provided to the carer, usually by mail, but with an email option, to allow the carer time to reflect upon the included items before Contact 2 occurs. At Contact 2, the FECH nurse guides the carer through the reflective CSNAT approach, using the CSNAT to identify and prioritise their support needs, then devising ways in which up to three prioritised needs will be addressed using problem solving techniques. This contact (first time of using the CSNAT approach) takes 45 minutes on average. At Contacts 3-6, each taking 30 minutes on average, the carer is prompted to reflect upon the extent to which support was accessed as planned since the previous contact, then again uses the CSNAT approach combined with problem-solving to identify, prioritise, and address remaining or additional support needs. Each contact point provides an opportunity to reinforce the problem-solving skills learnt. One of the aims of the intervention is to provide carers with problem solving skills that they can continue to use after the end of the intervention period. FECH nurses will emphasise the time-limited nature of their contact, and in each session encourage carers to actively use the skills discussed for identified problems, or the broader problem of future planning. At the last FECH nurse contact, carers and the nurse will review the strategies and resources used, highlighting which were most useful, and refreshing any skills that the carer feels unsure about. Carers will also be provided with an individualized summary sheet of the skills they can use, together with written resources. Process evaluation of FECH program implementation will address fidelity, safety, reach, and dose. Data will be collected by the FECH Nurses and recorded in hard copy then entered into an electronic database. Each nurse will document: (a) adherence to or deviation from planned FECH processes: (b) information provided to carers and the resources to which they were referred, (c) the extent to which carers engaged with resources (numbers and types of resources, how and when accessed, with what result [as planned or not and if not, why]); (d) any safety concerns identified by the FECH nurse and how these were managed; and (e) time taken to implement processes. Contextual factors that may be barriers to, or facilitators of, the effectiveness of the FECH program will also be recorded in the database. The extent to which implementation occurs as planned (fidelity) will be monitored, with steps taken by the investigators to ensure that this is maintained as soon as any indication of likely deviation is noted. To ensure this, one of the FECH program telephone calls will be recorded for each of the carers assigned to the intervention group. The State Project Managers will ensure that recordings are made of each of the 6 FECH contacts in approximately even numbers. Every 3 months during the FECH implementation period, a random audit and review of 5% of these recordings will be undertaken by one investigator, with feedback provided to the relevant State Project Manager and FECH nurses. In addition, (a) the State Project Manager will meet with the FECH Nurses on at least a fortnightly basis during the program to ascertain and address any threats to fidelity and (b) each State Project Manager will let the other know whenever a threat to fidelity has been determined in their state so that the action taken to address this threat is addressed in a similar manner in both states (as is appropriate). The extent of support accessed (dose) will be determined in two ways: (a) time spent during FECH contacts and (b) the extent to which identified needs are met as planned. Program reach will be established by comparing characteristics of those dyads assigned to receive the FECH program and continuing until program completion with characteristics of ‘non-completers’, taking into consideration reasons for withdrawal. References: 1. Ewing G, Austin L, Diffin J, Grande G. Developing a person-centred approach to carer assessment and support. Br J Community Nurs. 2015;20(12):580-4.