Background: Caregiver depression is common following a family member's stroke and is a major contributor of survivor's hospital readmission and institutionalization. Researchers have consistently found that interventions to help caregivers resolve problems are effective in reducing depressive symptoms. However, these problem-solving interventions have been underused in practice because they involve multiple, in-person or telephone sessions and require large amounts of staff time to implement. To overcome these barriers, our long-term goal is to implement stroke caregiver programs that involve low-cost interventions that are sustainable in routine clinical practice. Our immediate objective is to test, using a randomized controlled trial, a problem-solving intervention for stroke caregivers that can be delivered during the Veterans' in-patient stays followed by online, in-home sessions. We will modify the traditional, problem-solving intervention by adding web-based training using interactive modules, factsheets, and tools on our previously developed and nationally available RESCUE Caregiver website (www.rorc.research.va.gov/rescue). We will also provide on-line, skills training and application of the problem-solving approach via the RESCUE messaging center, a secure site behind the VA firewall. This work builds on the team's extensive experience in stroke caregiver education. Our immediate, primary aim (#1) is to test the effect of the intervention on stroke caregivers' depressive symptoms at 14 weeks post-discharge from in-patient settings. Primary Hypothesis: Stroke caregivers who receive the intervention will have less depressive symptoms at 14 weeks compared to stroke caregivers in the attention control group. We propose four secondary aims.
Aim #2 is to test the effect of the intervention on stroke caregivers' burden, problem-solving abilities, self-efficacy, health-related quality of life (HRQOL, and satisfaction with care at 14 weeks post-discharge.
Aim #3 is to test the effect of the intervention on Veterans' outcomes: functional abilities and healthcare utilization (i.e., unintended hospital bed days of care, number of emergency room visits, number of unscheduled clinic visits) at 14 weeks post-discharge.
Aim #4 is to determine the budgetary impact for implementing the intervention.
Aim #5 is to determine the facilitators, barriers and best practices for implementing the intervention. Methods: We will conduct a two-group randomized controlled trial with repeated measures and use mixed methods to determine caregivers' perceptions of the intervention. We will enroll 240 stroke caregivers at 3 study sites (North Florida/South Georgia Veterans Healthcare System, Miami VA Healthcare System, and James A. Haley Veterans Hospital in Tampa) in VISN8. Eligible caregivers will be interviewed, complete baseline measures, and then be randomized to two groups: 1) intervention group, or 2) attention control group. A research assistant (RA) will telephone caregivers at 7 weeks and 14 weeks to answer questions on instruments with established reliability and validity. The RA will review the Veterans' VA Computerized Patient Record System health record to obtain information on the Veterans' healthcare utilization. We will determine the budgetary impact of the intervention by examining the cost data in the Decision Support System National Data Extracts and VA fee-basis files. Qualitative interviews will be conducted with selected caregivers to obtain in-depth perceptions of the value, facilitators, and barriers of the intervention. Throughout all phases of the project, we will collaborate with our VA (Offices of Nursing Service, Office of Geriatrics and Extended Care, My HealtheVet Program Office, Stroke QUERI Center) and non-VA partners (American Stroke Association). Impact: This is the first known study to test a discharge-planning intervention combined with technology to improve the quality of caregiving and the recovery of Veterans. Other outcomes will be a state-of-the-art website and an evidence-based model (in-patient, discharge planning and online, training and caregiver-provider messaging) that can be transportable to other disease models.
The intervention tested in this project is novel and is the first to evaluate a problem-solving intervention for stroke caregivers that can be delivered during the Veterans' hospital stay, followed by online, in-home sessions. The intervention has the potential to reduce stroke caregiver depression, improve the recovery of Veterans post-stroke, enable Veterans to remain in their homes, and reduce healthcare costs. Other outcomes will be a state-of-the-art caregiver website and an evidence-based model (in-patient, discharge planning and online, training and messaging between providers and caregivers) that can be transportable to other disease models.
