Project Summary
The transition from hospital to home is a high-risk period for patients. When patients, or their families, are not well prepared for discharge, they are at risk for adverse events and may subsequently need to use the emergency department (ED) or get readmitted. Transitional care interventions, developed to support patients being discharged from the hospital, have been shown to result in reduced use of the hospital or ED. These interventions mainly focus on following patients for 30 days post discharge, addressing medication and outpatient follow-up issues. There is little evidence on the effect of these interventions on meaningful outcomes to patients, such as reduced shortness of breath and improved ability to walk or climb stairs. In this study, we propose to develop and evaluate a comprehensive patient- and family-centered transitional care intervention to improve patient-centered outcomes among hospitalized patients. We will focus the study on Chronic Obstructive Pulmonary Disease (COPD) patients, given that these patients commonly experience severe symptoms and frequently visit the ED or get hospitalized. The study will answer the following: Among patients hospitalized due to COPD, would patient/family engagement in a hospital-initiated three-month transitional care program that addresses the patient’s biopsychosocial needs and advances the patient/family caregiver ability to manage the disease improve the patient’s health-related quality of life and reduce number of hospitalizations and ED visits? Would this program improve family caregiver coping skills and reduce caregiver stress? Specifically, we aim to: 1) develop and pilot-test a Patient- and Family-Centered Transitional Care Intervention (PFI) that starts within hospital and continues for three months. The program will help meet hospitalized patients’ individual needs and build capacity of COPD patients/family caregivers to manage this disease and advance their problem-solving and coping skills; 2) conduct a randomized controlled trial, recruiting 214 patients admitted to one academic center, to measure the effects of PFI on health-related quality of life, survival, and rates of re-hospitalizations and ED visits, compared to usual care; 3) evaluate PFI impact on patient activation, confidence, and behaviors; and 4) evaluate impact on family caregiver confidence, stress, and coping skills. COPD patients dread getting severe shortness of breath that requires them to go to the ED or hospital. Many patients suffer from symptoms that limit their ability to perform their daily activities. Our primary study outcomes are to measure patients’ quality of life and the combined number of hospital and ED visits per patient over the six months post discharge. Other study measures that are highly relevant to patients and family caregivers include patient survival, symptom burden, and experience of care and family caregiver stress and coping skills.
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