Mathew Reeves, BVSc, PhD, is the principal investigator for a PCORI-funded project that compares usual care to a patient- and caregiver-centered case management program delivered by social workers, along with a web-based patient and caregiver portal, to determine if they improve transitions and outcomes for stroke patients who have returned home.

In the Michigan Stroke Transitions Trial (MISTT), Mathew Reeves, PhD, examines the effectiveness of a case management intervention designed to enhance care transitions for stroke patients. The two intervention arms for MISTT include a home-based case management program (provided by social workers) and access to an online information and support resource (a website). A fundamental principle of this research is its patient-centered approach that allows patients to interact with the case managers and the website as much as they choose.

“There is a wide range of engagement with these patients. Some have minimal needs or don’t want to develop a strong relationship. On the other hand, there are patients who want all the help they can get, which takes a larger commitment of staff time,” Reeves reports.

To understand how best to use staff time, Reeves tracked the resources required to implement the two interventions (case management and website access). The resource assessment is vital for decision makers to eventually be able to evaluate the program’s potential in different settings.

The social workers document every interaction—including time, topics discussed, and services provided. The project maintains a database of all interactions that includes the frequency, duration, type, and context of interactions. This data will help inform future workforce requirements needed to implement the study in other locations.

Reeves notes, “Right now, we are interested in documenting patient outcomes and the number and type of interactions that are a part of the intervention. However, eventually it will be important to generate a comprehensive assessment of the resources needed to implement the intervention—how many staff and what type—for a given set of patients.”

Advice for Others

  • Carefully plan for the data you will need to collect to track resource use.
  • Invest in an easy-to-use documentation system to reduce the data collection burden and allow automated coding of interactions.
  • Relay the rationale for why the data are a priority, since busy study staff may not appreciate the need to document resources.
  • Understand that a patient-centered approach will likely lead to much more patient-to-patient variation in the delivery of the intervention; therefore, ongoing documentation will help inform the resources needed to implement such programs in the future.

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