Trial Outcomes & Findings for Adapting Connect-Home Transitional Care for the Unique Needs of Persons With Alzheimer's Disease and Other Dementias and Their Caregivers (NCT NCT05887388)

Last Updated: 2023-07-21

Results Overview

Feasibility will measured using an instrument to audit skilled nursing facility medical records of the patient and the intervention log of services for the Patient and Caregiver dyad. It includes eight dichotomous (yes-no) items that indicate feasibility of the Connect-Home Plus intervention. The feasibility items include: (1) completing the Transition Plan of Care; (2) convening the care plan meeting with caregiver attending; (3) reviewing advance directives in the SNF; (4) scheduling follow-up medical appointments; (5) transmitting records to follow-up clinicians; (6) home care nurse completion of the first home visit within 24 hours after discharge; (7) completion of first caregiver support call within 72 hours of discharge; (8) completion of the second and third caregiver support call within one month of discharge. A "Yes" answer indicates that the intervention component was feasible to provide for the patient and caregiver dyad.

Recruitment status

COMPLETED

Study phase

Target enrollment

38 participants

Primary outcome timeframe

30 days after SNF discharge

Results posted on

2023-07-21

Participant Flow

Participant milestones

Participant milestones
Measure	Intervention Connect-Home Plus will be delivered in the skilled nursing facility (SNF) and via telephone after discharge. Connect-Home Plus: Connect-Home Plus will introduce organizational structure to support delivery of transitional care processes. New elements of structure include:electronic health record (EHR) template, Connect-Home Plus Toolkit, and Staff Training. After structural elements are added, SNF staff will use Connect-Home Plus care processes to deliver the 2-step transitional care intervention.In Step 1, SNF nurses,therapists, and social workers will develop a Transition Plan of Care and prepare the patient and caregiver to manage the illness and functional needs. In Step 2, a home health care nurse will visit (one time) and a dementia caregiving specialist will call the patient's home three times within 30 days of discharge. Both intervention steps will focus on key care needs, such as 1) home safety; 2) care of symptoms of Alzheimer's disease and related dementia (ADRD); 3) symptom management; 4) medication reconciliation; 5) function and activity; and 6) coordination of follow-up medical care.
Overall Study STARTED	38
Overall Study Patients Started	19
Overall Study Caregivers Started	19
Overall Study COMPLETED	38
Overall Study NOT COMPLETED	0

Reasons for withdrawal

Withdrawal data not reported

Baseline Characteristics

Data are reported separately for Patients and Caregivers.

Baseline characteristics by cohort

Baseline characteristics by cohort
Measure	Intervention n=38 Participants Connect-Home Plus will be delivered in the skilled nursing facility and via telephone after discharge.
Age, Continuous Patients	85.4 years STANDARD_DEVIATION 6.8 • n=19 Participants • Data are reported separately for Patients and Caregivers.
Age, Continuous Caregivers	61.8 years STANDARD_DEVIATION 11.4 • n=19 Participants • Data are reported separately for Patients and Caregivers.
Sex: Female, Male Patients · Female	15 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Sex: Female, Male Patients · Male	4 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Sex: Female, Male Caregivers · Female	13 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Sex: Female, Male Caregivers · Male	6 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Ethnicity (NIH/OMB) Patients · Hispanic or Latino	0 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Ethnicity (NIH/OMB) Patients · Not Hispanic or Latino	19 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Ethnicity (NIH/OMB) Patients · Unknown or Not Reported	0 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Ethnicity (NIH/OMB) Caregivers · Hispanic or Latino	0 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Ethnicity (NIH/OMB) Caregivers · Not Hispanic or Latino	19 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Ethnicity (NIH/OMB) Caregivers · Unknown or Not Reported	0 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Race (NIH/OMB) Patients · American Indian or Alaska Native	0 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Race (NIH/OMB) Patients · Asian	0 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Race (NIH/OMB) Patients · Native Hawaiian or Other Pacific Islander	0 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Race (NIH/OMB) Patients · Black or African American	1 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Race (NIH/OMB) Patients · White	18 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Race (NIH/OMB) Patients · More than one race	0 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Race (NIH/OMB) Patients · Unknown or Not Reported	0 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Race (NIH/OMB) Caregivers · American Indian or Alaska Native	0 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Race (NIH/OMB) Caregivers · Asian	0 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Race (NIH/OMB) Caregivers · Native Hawaiian or Other Pacific Islander	0 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Race (NIH/OMB) Caregivers · Black or African American	1 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Race (NIH/OMB) Caregivers · White	18 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Race (NIH/OMB) Caregivers · More than one race	0 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Race (NIH/OMB) Caregivers · Unknown or Not Reported	0 Participants n=19 Participants • Data are reported separately for Patients and Caregivers.
Region of Enrollment United States · Patients	19 Participants n=38 Participants
Region of Enrollment United States · Caregivers	19 Participants n=38 Participants

PRIMARY outcome

Timeframe: 30 days after SNF discharge

Population: Data are reported only for Patients as this measure does not apply to Caregivers.

Outcome measures

Outcome measures
Measure	Connect-Home Plus Patients n=19 Participants Connect-Home Plus will be delivered in the skilled nursing facility and via telephone after discharge.
Number of Patients for Whom the Intervention Components Were Feasible Record transmission	19 Participants
Number of Patients for Whom the Intervention Components Were Feasible Call back #1 within 72 hours	17 Participants
Number of Patients for Whom the Intervention Components Were Feasible Transition Plan of Care	16 Participants
Number of Patients for Whom the Intervention Components Were Feasible Care plan meeting	19 Participants
Number of Patients for Whom the Intervention Components Were Feasible Advance directives	15 Participants
Number of Patients for Whom the Intervention Components Were Feasible Follow-up medical appointments	16 Participants
Number of Patients for Whom the Intervention Components Were Feasible Home visit within 24 hours	17 Participants
Number of Patients for Whom the Intervention Components Were Feasible Call back #2 and #3 within 30 days	16 Participants

PRIMARY outcome

Timeframe: 21 days after SNF discharge

Population: Data are reported only for Patients as this measure does not apply to Caregivers. Fifteen Patients were unable or unavailable to participate in data collection for this measure.

This interview guide will be used to assess the acceptability of Connect-Home Plus with persons with ADRD. The interview will include questions about (1) factors that made the Connect-Home Plus transitional care services easy or difficult to use, (2) specific supports that were and were not helpful, (3) the effect of Connect-Home Plus on how to manage issues related to ADRD at home, and (4) unmet needs for care of issues related to ADRD at home. Responses to the interview guide questions will be used to generate 3 4-point Likert scale acceptability scores, including (1) how helpful was Connect-Home Plus, (2) how difficult were these services to use, and (3) how well did these services prepare you for care at home. The scores will include 0 meaning not applicable, and scores 1-3 indicating acceptability, with lower scores indicating higher acceptability.

Outcome measures

Outcome measures
Measure	Connect-Home Plus Patients n=4 Participants Connect-Home Plus will be delivered in the skilled nursing facility and via telephone after discharge.
Mean Patient Intervention Satisfaction Scores Helpfulness	1.0 score on a scale Standard Deviation 0
Mean Patient Intervention Satisfaction Scores Usefulness	1.0 score on a scale Standard Deviation 0
Mean Patient Intervention Satisfaction Scores Appropriateness	1.0 score on a scale Standard Deviation 0

PRIMARY outcome

Timeframe: 21 days after SNF discharge

Population: Data are reported only for Caregivers as this measure does not apply to Patients. Seven Caregivers were unavailable to participate in data collection for this measure.

This interview guide will be used to assess the acceptability of Connect-Home Plus with caregivers of persons with ADRD. This interview guide will include questions about (1) factors that made the Connect-Home Plus transitional care services easy or difficult to use, (2) specific supports that were and were not helpful, (3) the effect of Connect-Home Plus on how to manage issues related to ADRD at home, and (4) unmet needs for care of issues related to ADRD at home. Responses to the interview guide questions will be used to generate 3 4-point Likert scale acceptability scores, including (1) how helpful was Connect-Home Plus, (2) how difficult were these services to use, and (3) how well did these services prepare you for care at home. The scores will include 0 meaning not applicable, and scores 1-3 indicating acceptability, with lower scores indicating higher acceptability

Outcome measures

Outcome measures
Measure	Connect-Home Plus Patients n=12 Participants Connect-Home Plus will be delivered in the skilled nursing facility and via telephone after discharge.
Mean Caregiver Intervention Satisfaction Scores Helpfulness	1.3 score on a scale Standard Deviation 0.5
Mean Caregiver Intervention Satisfaction Scores Usefulness	1.0 score on a scale Standard Deviation 0
Mean Caregiver Intervention Satisfaction Scores Appropriateness	1.3 score on a scale Standard Deviation 0.5

SECONDARY outcome

Timeframe: 7 Days After SNF Discharge

Population: Data are reported only for Patients as this measure does not apply to Caregivers and data are reported by the Patient (or the Caregiver serving as a proxy). Participants were unavailable for data collection for 3 Patients.

The patient's preparedness for discharge will be measured by the Care Transitions Measure-15 (CTM-15), which includes 15 items on a 4-point scale. The CTM-15 measures self-reported knowledge and skills for continuing care at home. Summary scores range 0-100, with higher scores indicating greater preparedness. Data collected from either the Patient or the Caregiver serving as proxy.

Outcome measures

Outcome measures
Measure	Connect-Home Plus Patients n=16 Participants Connect-Home Plus will be delivered in the skilled nursing facility and via telephone after discharge.
Care Transitions Measure-15 (Patient)	70.3 score on a scale Standard Deviation 12.0

SECONDARY outcome

Timeframe: 7 Days After SNF Discharge

Population: Data are reported only for Caregivers as this measure does not apply to Patients. Three Caregivers were unavailable for data collection for this measure.

The caregiver's preparedness for caregiving will be measured by the Preparedness for Caregiving Scale (PCS), which includes 8 items on a five-point Likert scale (0-4). The PCS measures self-reported readiness for caregiving. Range = 0-32, with higher scores associated with greater preparedness.