Helping Invested Families Improve Veterans Experiences Study

Anticipated Impacts on Veteran's Healthcare: Designing and implementing a training program
for informal caregivers of functionally impaired Veterans (HI-FIVES) will enhance Veterans'
ability to remain in their homes and satisfaction with care, as well as lower VA costs.
Caregiver training can also improve caregiver wellbeing by alleviating feelings of depression
and burden, which can also improve the care they provide to veterans. The investigators'
caregiver training program is consistent with features of two recent national policy changes
aimed to improve quality of care for veterans. First, providing training to informal
caregivers of functionally impaired veterans is consistent with the 2000 Millennium Health
Care Act, which mandated an unprecedented expansion in long-term care benefits to Veterans,
and stipulated that, whenever possible, care be provided in the least restrictive environment
possible-the home. Second, The Caregivers and Veterans Omnibus Health Services Act of 2010
mandated unprecedented support for informal caregivers of severely injured Operation Enduring
Freedom/Operation Iraqi Freedom(OEF/OIF) Veterans, including providing caregiver training to
informal caregivers of any era veteran. Achieving higher quality informal care supports both
of these mandates. By partnering with VA providers, HI-FIVES will improve the skill of
caregivers, thereby improving veteran health care quality and the ability for veterans to
remain at home.

Project Background: Caregiver burnout, strain and burden are associated with caregiver
depression and patient institutionalization. Furthermore, lack of skills among caregivers can
lead to depression and anxiety as well as patient institutionalization. The investigators
propose to evaluate an innovative program that supports and trains informal caregivers when
veterans are referred to Veterans Health Administration (VHA) home and community-based care
(HCBC), a critical moment in a veteran's VHA health care use trajectory. Referral to HCBC is
a time when caregivers may face personal strain and uncertainty about demands involved in
caregiving. As such, it presents a teachable moment to train caregivers to better meet the
demands imposed by caregiving.

Project Objectives: To evaluate whether over 12 months, veterans with caregivers in the skill
training program have clinically significant increases in days at home than veterans in usual
care (e.g. days not in emergency department, hospital, or nursing home). In addition, the
investigators will evaluate whether veterans in the skill training program have significantly
lower VA costs of medical care or higher satisfaction with VHA over 6 and 12 months than
veterans in usual care. Finally, the investigators will evaluate whether caregivers in the
skill training program have clinically significant reductions in depressive symptoms,
subjective burden, or increased satisfaction with VA healthcare at 6 and12 months than
caregivers in usual care.

Project Methods: The study is a randomized controlled trial with data collection from
caregiver-patient dyads before and after training, and at 6 and 12 months after program
completion. Piloted in early 2012, the setting is the Social Work Service at the Durham VA
Medical Center (VAMC). Patient inclusion criteria are patient referred to home and
community-based services in the past 3 months, not eligible for hospice, residing at home,
has an informal caregiver, and willing to let investigators contact the caregiver. Caregivers
must be cognitively and physically capable to participate, understand English, not be treated
for a substance abuse disorder, not be in another caregiver interventional study, and willing
to participate in 3 phone call trainings and attend five group sessions at the VA. Caregivers
in the control group will receive the training and support usually provided by HCBC and VA
medical providers. To be referred successfully to HCBC, patients will have a minimum of 2
activity of daily living limitations, and are likely to have multimorbidity, including high
rates of cognitive impairment (44% in the pilot). The target sample size will be 146
caregivers in each arm. Patient involvement will be limited to four short phone assessments
(with mechanisms established for proxy respondents). Caregivers in the treatment arm will
take part in three phone training sessions and five group sessions, and in both arms
caregivers will be asked to provide four phone assessments. Descriptive statistics will be
used to summarize all study variables. Of primary importance will be to examine the
distribution of patient days spent at home during the first 3 months, the first 6 months, and
over the entire 12 months of the post-intervention period (e.g. days not in ED, inpatient, or
nursing home setting). Investigators will use the count-data regression model which best fits
the investigators' data (Poisson, Negative Binomial or zero-inflated versions of Poisson or
Negative Binomial) to test the primary hypothesis that veterans with caregivers in the skill
training program will have significantly more days spent at home than veterans in usual care.

Inclusion Criteria:

- Patient referred to home and community-based services in the past 3 months,

- not eligible for hospice,

- residing at home,

- has an informal caregiver, and willing to let us contact the caregiver.

To be referred successfully to HCBC,

- patients will have a minimum of 2 activity of daily living limitations,

- and are likely to have multimorbidity, including high rates of cognitive impairment.

Exclusion Criteria:

- Cognitively impaired Caregiver

- Caregiver does not have access to a telephone.

- Severely impaired hearing or speech (Caregivers must be able to respond to phone
calls).

- English Language Impaired - Caregiver

- Substance Abuse Disorders - Caregiver

- Caregiver participating in other caregiver intervention

- Patient referred only for physical or occupational therapy

- Patient or caregiver refuses informed consent

- Patient in hospital