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MRP 05-311 – HSR&D Study

 
MRP 05-311
Enhancing Home-based Long-term Care for High Risk Frail Veterans: A Tailored Caregiver Training Intervention
Courtney H Van Houtven PhD
Durham VA Medical Center, Durham, NC
Durham, NC
Funding Period: October 2006 - September 2012

BACKGROUND/RATIONALE:
Caring for a functionally impaired elderly family member or friend in the home (informal care) is the most common form of long-term care (LTC) provided in the U.S. and offers a huge benefit to society by allowing functionally impaired adults to remain in their preferred setting-the home-and by substituting for costly formal long-term care (LTC), including nursing homes.2, 3 5 Approximately 45 million American adults provided informal care in 2009.6 8.5 million of the 22 million care recipients were Veterans.7 However, there are unintended consequences of informal care given strain, burden and burnout are highly prevalent in caregivers. Furthermore, the consequences are associated with caregiver depression and patient institutionalization.8,9,10,11Caregiver interventions have exhibited modest improvements in depressive symptoms and subjective burden for caregivers. Programs that combine individual and group counseling, furthermore, have reduced institutionalization of care recipients,12-14 However, many programs do not affect institutionalization or health care costs. Notably, most studies focus on caregiver outcomes and have not been powered to detect changes in nursing home entry or patient costs.8, 15 Thus, the lack of compelling evidence that caregiver skills training can save health system costs could be attributed to lack of statistical power, just as readily as to lack of effectiveness.

The 1999 Millennium Act, which, in addition to exponentially expanding coverage of LTC for Veterans, stipulated that Veterans receive care in the least restrictive setting possible-their homes. Thus, the VA must consider strategies that increase Veterans' days at home. Even with home and community-based care (HCBC) offered by the VA, such as skilled home health, homemaker home health aide, or home-based primary care, Veterans rarely can remain in their homes without help from willing, qualified informal caregivers.

We propose to evaluate an innovative program that supports and trains informal caregivers when Veterans are referred to HCBC, a critical moment in a Veteran's VHA health care use trajectory. Referral to HCBC is a time that caregivers may face personal strain and uncertainty about demands involved in caregiving. As such, it presents a teachable moment to train caregivers for the demands imposed by caregiving. Training caregivers at this critical moment has great potential to enhance VHA quality of health care, improve Veteran and caregiver well-being, improve medication adherence, lower Veteran costs of care and increase satisfaction by maintaining Veterans at home. If effective and cost-saving, this program could directly change care delivery on a national scale by offering a standardized caregiver training curriculum when Veterans first receive a HCBC referral. Thus, the objective of this research, responding directly to HSR&D's priority "Long-term Care and Caregiving" is to examine a caregiver skill training program, Helping Invested Families Improve Veterans Experiences Study (HI-FIVES). The program is comprised of a 12-week evidence-based targeted individual phone and group in-person training curriculum; modules focus on enhancing clinical skills, psychological skills (including self-care), and support seeking skills. Importantly, we remove financial barriers to participation that caregivers typically face, in order to increase uptake and retention.

OBJECTIVE(S):
We will test the following hypotheses:
Primary :
(H1) At 12 months post-treatment, Veterans with caregivers in the skill training program (HI-FIVES) will have clinically significant increases in days at home compared to Veterans in usual care.
Secondary:
(H2) At 12 months post-treatment, Veterans with caregivers in the skill training program (HI-FIVES) will have significant reductions in total VA health care costs compared to Veterans in usual care.
(H3) Post-treatment, caregivers and Veterans with caregivers in the skill training program (HI-FIVES) will have significantly higher satisfaction with VHA health care compared to caregivers and Veterans in usual care.
(H4) Post-treatment, caregivers in the skill training program (HI-FIVES) will have clinically significantly lower depressive symptoms compared to caregivers in usual care.

METHODS:
This study will be a randomized controlled trial of a 12-week, individual and group-based skill training program for caregivers of functionally impaired Veterans who have been referred to receive home-based care (HCBC). Following consent and baseline assessments of the caregiver and the patient, caregivers will be randomly assigned with equal allocation to one of two groups, stratified by a patient's cognitive impairment status: skill training or usual care. Briefly, the skill training arms will each include three individual calls with a nurse educator to formulate and address topics the caregiver identifies as his or her highest priority learning areas. Additionally, each subject will participate in an evidence-based curriculum aimed to improve clinical care skills, psychological care skills, and support seeking skills. Four group visits will occur over a 4-week period, with group sizes of 8-10 informal caregivers. Finally, there will be two booster phone calls at 1 and 3 months post intervention.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
This study is significant for the following reasons: First, supporting caregivers of Veterans is a national priority for the VHA and key legislation has been passed to directly pay and train caregivers of defined patient cohorts. We will inform this emerging legislative effort by examining how other efforts to remove financial barriers (to encourage participation in training) affect key patient and caregiver outcomes. Second, patients referred to receive HCBC are at a crisis point in their health care management and in the episode of caregiving. The time of referral means that caregivers are at a high risk of burnout and supporting caregivers to enable them to provide the highest quality of care at this particular moment, is in the interest of the VA. Such an intervention may optimize patient outcomes and reduce patient costs in the short and long-term. Caregivers, by seeking a long-term care referral (or by the physician or social worker initiating one), signals that the current care situation is not working. More services are needed to successfully support the patient in the home. Third, the caregiver group and telephone-based training components of the intervention have been developed based on evidence, and in a way that they will be feasible to disseminate in typical VA clinical settings at relatively low cost and effort. Removing financial barriers will facilitate involvement by even the most economically vulnerable caregivers. Involvement of the advisory board will ensure the program is implementable and if found to be effective. Once developed for this study, these programs can be utilized elsewhere in the VA healthcare system, under the guidance of the advisory board.


External Links for this Project

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PUBLICATIONS:

Journal Articles

  1. Van Houtven CH, Voils CI, Weinberger M. An organizing framework for informal caregiver interventions: detailing caregiving activities and caregiver and care recipient outcomes to optimize evaluation efforts. BMC geriatrics. 2011 Nov 22; 11:77. [view]
  2. Thorpe JM, Van Houtven CH, Sleath BL, Clipp EC. Barriers to Outpatient Care in Community-Dwelling Elderly with Dementia: The Role of Caregiver Life Satisfaction. Journal of applied gerontology : the official journal of the Southern Gerontological Society. 2009 Aug 1; 28(4):436-460. [view]
  3. Coe NB, Van Houtven CH. Caring for mom and neglecting yourself? The health effects of caring for an elderly parent. Health economics. 2009 Sep 1; 18(9):991-1010. [view]
  4. Taylor DH, Steinhauser K, Tulsky JA, Rattliff J, Van Houtven CH. Characterizing hospice discharge patterns in a nationally representative sample of the elderly, 1993-2000. The American journal of hospice & palliative care. 2008 Feb 1; 25(1):9-15. [view]
  5. Wilson, Van Houtven CH, Stears, Clipp EC. Depression and Missed Work Among Caregivers. Journal of Family and Economic Issues. 2007 Nov 2; 28(4):684-698. [view]
  6. Van Houtven CH, Ramsey SD, Hornbrook MC, Atienza AA, van Ryn M. Economic burden for informal caregivers of lung and colorectal cancer patients. The Oncologist. 2010 Dec 27; 15(8):883-93. [view]
  7. Wang V, Smith VA, Bosworth HB, Oddone EZ, Olsen MK, McCant F, Powers BJ, Van Houtven CH. Economic evaluation of telephone self-management interventions for blood pressure control. American heart journal. 2012 Jun 1; 163(6):980-6. [view]
  8. Bosworth HB, Powers BJ, Olsen MK, McCant F, Grubber J, Smith V, Gentry PW, Rose C, Van Houtven C, Wang V, Goldstein MK, Oddone EZ. Home blood pressure management and improved blood pressure control: results from a randomized controlled trial. Archives of internal medicine. 2011 Jul 11; 171(13):1173-80. [view]
  9. Van Houtven CH, Jeffreys AS, Coffman CJ. Home health care and patterns of subsequent VA and Medicare health care utilization for veterans. The Gerontologist. 2008 Oct 1; 48(5):668-78. [view]
  10. Van Houtven CH, Oddone EZ, Weinberger M. Informal and formal care infrastructure and perceived need for caregiver training for frail US veterans referred to home and community-based services. Chronic Illness. 2010 Mar 1; 6(1):57-66. [view]
  11. Van Houtven CH, Norton EC. Informal care and Medicare expenditures: testing for heterogeneous treatment effects. Journal of Health Economics. 2008 Jan 1; 27(1):134-56. [view]
  12. Van Houtven CH, Taylor DH, Steinhauser K, Tulsky JA. Is a home-care network necessary to access the Medicare hospice benefit? Journal of palliative medicine. 2009 Aug 1; 12(8):687-94. [view]
  13. Van Houtven CH, Friedemann-Sánchez G, Clothier B, Levison D, Taylor BC, Jensen AC, Phelan SM, Griffin JM. Is policy well-targeted to remedy financial strain among caregivers of severely injured U.S. service members? Inquiry : A Journal of Medical Care Organization, Provision and Financing. 2012 Jan 1; 49(4):339-51. [view]
  14. van Ryn M, Sanders S, Kahn K, van Houtven C, Griffin JM, Martin M, Atienza AA, Phelan S, Finstad D, Rowland J. Objective burden, resources, and other stressors among informal cancer caregivers: a hidden quality issue? Psycho-oncology. 2011 Jan 1; 20(1):44-52. [view]
  15. Hendrix CC, Hastings SN, Van Houtven C, Steinhauser K, Chapman J, Ervin T, Sanders L, Weinberger M. Pilot study: individualized training for caregivers of hospitalized older veterans. Nursing Research. 2011 Nov 1; 60(6):436-41. [view]
  16. Thorpe JM, Van Houtven CH, Sleath BL, Thorpe CT. Rural-urban differences in preventable hospitalizations among community-dwelling veterans with dementia. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2010 Mar 1; 26(2):146-55. [view]
  17. Taylor DH, Ostermann J, Van Houtven CH, Tulsky JA, Steinhauser K. What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Social science & medicine. 2007 Oct 1; 65(7):1466-78. [view]
Book Chapters

  1. Van Houtven CH, Weinberger M, Carey T. Implications of Nonadherence for Economic Evaluation and Health Policy. In: Bosworth HB, Oddone EZ, editors. Patient Treatment Adherence: Concepts, Intervention and Measurement. 1 ed. Mahwah, NJ: Lawrence Erlbaum Associates; 2005. Chapter 14. 421-451 p. [view]
Conference Presentations

  1. Van Houtven C. A conceptual model of caregiver programs and caregiver and care recipient outcomes. Paper presented at: University of North Carolina Chapel Hill Institute on Aging Annual Seminar; 2006 Nov 29; Chapel Hill, NC. [view]
  2. Van Houtven CH, Griffin JM. A white paper on the current status of findings from informal caregiving research and recommendations for the VA. Paper presented at: VA Supporting Veterans At Home Conference; 2010 Jul 12; Arlington, VA. [view]
  3. Wang V, Smith V, Oddone EZ, Olsen MK, McCant FA, Van Houtven CH. Cost analysis of a four-arm home- and telephone-based intervention for blood pressure management among primary care patients with hypertension. Paper presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD. [view]
  4. Van Houtven. Development of a Nurse-Led Intervention for Maintaining Frail Veterans at Home. Paper presented at: Duke University School of Nursing Trajectories of Aging and Care Center Research Annual Seminar; 2007 Jun 12; Durham, NC. [view]
  5. Van Houtven C, Jeffreys A, Coffman C. Does home health care reduce subsequent VA and Medicare Utilization for Veterans? Paper presented at: University of Miami Southeastern Health Economics Study Group Annual Conference; 2006 Oct 6; Miami, FL. [view]
  6. Wang V, Smith V, Bosworth HB, Oddone EZ, Olsen MK, McCant FA, Van Houtven CH. Economic Evaluation of Three Telephone Self-Management Interventions for Blood Pressure. Paper presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD. [view]
  7. Van Houtven CH. Factors associated with financial strain among family caregivers of OEF/OIF polytrauma veterans. Presented at: International Health Economics Association Biennial World Congress on Health Economics; 2011 Jul 10; Toronto, Canada. [view]
  8. Van Houtven CH, Friedemann-Sanchez G, Clothier BA, Levison D, Taylor BC, Jensen AC, Phelan S, Griffin JM. Financial Strain Among Family Caregivers of OEF/OIF Service Members with Traumatic Brain Injury and Polytrauma. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD. [view]
  9. Van Houtven CH. Health Effects of Caring for Elderly Parents. Paper presented at: AcademyHealth Annual Research Meeting; 2009 Jun 29; Chicago, IL. [view]
  10. Van Houtven CH. Health, Work and Wealth Effects of Caring for Elderly Parents. Paper presented at: University of Lausanne Health Management and Organization Research Meeting; 2008 Mar 18; Tilburg, Netherlands. [view]
  11. Van Houtven CH. Health, Work and Wealth Effects of Caring for Elderly Parents. Presented at: Network for Studies on Pensions, Aging and Retirement Annual Conference; 2008 Jun 26; The Hague, Netherlands. [view]
  12. Van Houtven CH, Boles J, Weidenbacher HJ, Johnson MR, Gentry PW, Rose CM, Knight C, Hastings SN, Olsen MK, Hendrix CC, Oddone EZ, Weinberger M. Helping invested families improve Veterans’ experiences: Pilot study. Paper presented at: VA HSR&D Career Development Annual Meeting; 2012 Jul 16; National Harbor, MD. [view]
  13. Van Houtven C. How do patients, families and caregivers define value and how do we measure it? Paper presented at: Alzheimer's Association Research Annual Roundtable; 2006 Nov 7; Washington, DC. [view]
  14. Van Houtven CH. How to Improve Access to Health Care for Persons with Disabilities. Presented at: Association for Public Policy Analysis and Management Annual Conference; 2008 Nov 7; Los Angeles, CA. [view]
  15. Van Houtven C. Informal Care and Medicare Expenditures: Testing for Heterogeneous Treatment Effects. Paper presented at: Network for Studies on Pensions, Aging and Retirement Annual Conference; 2006 Oct 19; Netherlands. [view]
  16. Van Houtven CH. Informal Care Around the World. Paper presented at: Allied Social Science Associations Annual Meeting; 2008 Jan 4; New Orleans, LA. [view]
  17. Van Houtven CH, vdr Heijden E, Coe N. Intervivos Transfers, Altruism and Retirement Income Uncertainty: an Experimental Investigation. Poster session presented at: International Health Economics Association Biennial World Congress on Health Economics; 2011 Jul 10; Toronto, Canada. [view]
  18. Van Houtven CH. Is Informal Care Dynastic? The Role of Genetics and Preferences in Long-Term Care Insurance Decisions. Paper presented at: AcademyHealth Annual Research Meeting; 2010 Jun 29; Boston, MA. [view]
  19. Van Houtven CH. Is Informal Care Dynastic? The Role of Genetics and Preferences in Long-Term Care Insurance Decisions. Paper presented at: American Society of Health Economists Biennial Conference; 2010 Jun 22; Ithaca, NY. [view]
  20. Van Houtven CH. Is it Necessary to have a Home Care Network To Access Medicare's Hospice Benefit? Paper presented at: Network for Studies on Pensions, Aging and Retirement Annual Conference; 2007 Oct 15; Tilburg, Netherlands. [view]
  21. Van Houtven CH. Pilot Study: Helping Invested Families Improve Veterans Experiences. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 17; National Harbor, MD. [view]
  22. Van Houtven CH. Spousal Health Shocks and the Timing of the Retirement Decision in the Face of Forward-Looking Financial Incentives. Paper presented at: American Society of Health Economists Biennial Conference; 2010 Jun 22; Ithaca, NY. [view]
  23. Van Houtven CH. Spousal Health Shocks and the Timing of the Retirement Decision in the Face of Forward-Looking Financial Incentives. Paper presented at: International Health Economics Annual Health Econometrics Workshop; 2010 Sep 30; Berkeley, CA. [view]
  24. Van Houtven C, Taylor D, Steinhauser K, Tulsky JA. Trajectories of serious illness. Paper presented at: International Health Economics Association Biennial World Congress on Health Economics; 2007 Jul 11; Copenhagen, Denmark. [view]


DRA: Aging, Older Veterans' Health and Care
DRE: Treatment - Observational
Keywords: none
MeSH Terms: none

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