Dementia
Conditions
Keywords
Dementia, Transitional Care, Caregiver
Brief summary
The goal of the project is to conduct a prospective, randomized-controlled clinical trial to determine the extent to which the Coordinated-Transitional Care (C-TraC) program impacts transitional care quality, patient cognition/function, caregiver stress and 30-day rehospitalizations in patients with documented diagnoses of dementia discharged from the hospital to the community.
Detailed description
Patients with dementia often experience poor quality transitions from the hospital to the community. In response, the investigators developed and piloted the Coordinated-Transitional Care (C-TraC) program--a low-cost, telephone-based intervention designed to improve care coordination and outcomes in hospitalized patients with dementia or other high-risk conditions discharged to community settings. A single-blind, prospective, randomized-controlled trial will be used with participants being randomly assigned to receive usual (i.e. standard) care, or usual care plus the C-TraC intervention. Outcomes will be assessed via scheduled phone-calls at 14, 30, and 90 days post-hospitalization. A 45-day phone call will also be conducted to complete a brief satisfaction survey with the caregiver about their post-hospital experience.
Interventions
OTHERC-TraC Intervention
C-TraC utilizes a nurse case manager to coordinate the patient's transitional care through active participation in inpatient multidisciplinary discharge rounds, a single brief protocol-driven inpatient encounter, and 1-4 protocol-driven post-hospital telephone calls with the patient/caregiver using spaced retrieval techniques.
Sponsors
National Institute on Aging (NIA)
University of Wisconsin, Madison
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Patient Inclusion Criteria: * English-speaking * Have a working telephone * Hospitalized on medical inpatient wards at UWHC * A documented pre-hospitalization diagnosis of dementia. * Alzheimer's Disease Cooperative Study - Clinical Dementia Rating (ADCS-CDR) score of \> 0 * Have a family member/informal caregiver who has regular contact with them in the community setting Caregiver Inclusion Criteria: * English-speaking * Have a working telephone * Have contact with patient a minimum of once per week Patient
Exclusion criteria
* Discharged to institutional settings * No identified caregiver * Discharged to hospice * Followed by complex case management or any form of intensive case management (e.g. transplant, congestive heart failure, dialysis) * Score moderate-high on modified ASSIST tool for alcohol
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change from baseline in rehospitalizations at 14, 30 and 90-days | 14, 30 and 90-days | The presence of any rehospitalization will be assessed through a combination of 14, 30 and 90 day structured phone calls directly to patients/caregivers, a detailed review of medical records associated with any of these caregiver/patient reported rehospitalizations, and a detailed review of the patient's UWHC medical records after all phone calls are completed. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Increase in patient delirium prevention/resolution | 14, 30 and 90-days | To assess for delirium, the Family Confusion Assessment Method (FAM-CAM) will be used - an 11-item tool designed to detect delirium from the observations of family caregivers. |
| Patient functional maintenance/recovery | 14, 30 and 90-days | To assess function, the investigators will use the Alzheimer's Disease Co-operative Study - Activities of Daily Living Inventory (ADCS-ADL). ADCS-ADL is a 23 item tool which offers detailed descriptions of each functional activity and asks caregivers to describe the patient's observed actions or behaviors. |
| Patient falls prevention | 14, 30 and 90-days | Caregivers will be asked to report the presence and dates of any patient falls since discharge. |
| Decrease caregiver stress | 14, 30 and 90-days | To measure caregiver stress the 22-item Zarit Caregiver Burden Scale and the 6-item Caregiver Activation Survey (CAS) will be used. The Zarit Caregiver Burden Scale is used as a measure of caregiver psychological stress and the CAS is used as a measure of time spent caregiving. The investigators will also assess caregiver stress using the 9-item Patient Health Questionnaire (PHQ-9) and the 3-item Care Transitions Measure (CTM-3). The PHQ-9 is used to establish provisional depressive disorder diagnoses as well as grade the severity of depressive symptoms. The CTM-3 has been modified to be given to caregivers discussing their experience with coordinating their loved ones care after hospital discharge. The statements ask about when the loved one was in the hospital, when they were preparing to leave the hospital and about their medications. |
Countries
United States
Outcome results
None listed