Evaluating Patient-Focused Versus Patient and Family Caregiver Support in Acute Care Transitions for Older Adults

What this Trial Is About

This research aims to find better ways to support older adults and their family caregivers during the transition from hospital to home. It compares two acute care transition programs to see if adding family caregiver support to patient-focused care helps patients stay safely at home and reduces the time they spend in hospitals or emergency rooms. The study also looks at whether this family-centered approach improves patients ability to carry out daily activities and reduces caregiving burden. Participants will be randomly assigned to one of two groups. The first group receives an active care transition program focused on patient needs, including assessments, discharge planning, education, and follow-up. The second group receives the same patient-focused program plus additional family caregiver support such as caregiver needs assessment, structured education, and skill building. The study uses telephone, video calls, and other technologies to involve families across urban and rural areas in five states. During the study, participants and their family caregivers will be assessed through surveys and interviews at multiple time points up to 180 days after discharge. Researchers will measure hospital-free days, readmissions, patient and caregiver outcomes like caregiver burden, social role participation, and satisfaction with care transitions. The study also tracks access to community services, outpatient follow-up, and cognitive status, aiming to better understand and improve the hospital-to-home transition experience for older adults and their families.

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