Academic-Practice Partnership for Caregiver Training and Support

Discussion

Based on published evidence that caregiver training and support may deliver favorable caregiver and patient outcomes, we developed and pilot-tested the feasibility of the DEFT program in an academic medical center [11, 15-16]. The DEFT team's careful deliberation in designing its workflow to minimize, as much as possible, disruptions to hospital services may have contributed to the initial acceptance of the program by hospital providers. The ability to access medical records via EPIC has also allowed the DEFT team to tailor the training and education based on patients' medical conditions.

Although an academic-practice partnership is touted as a collaborative opportunity in health care, this endeavor is replete with complexities [33, 34]. The operating systems of academic institutions and practice systems are vastly dissimilar. Academic faculty and personnel often lack the operational knowledge about hospital services and work culture. They also have limited top-level participation in hospital decision-making processes. To launch a health-system-wide initiative, buy-in from key stakeholders and hospital leadership is crucial. In DEFT's case, the team engaged in many presentations to hospital leadership to disseminate widely how DEFT can provide value-added benefits to the health system. Authorship in national presentations involved clinical partners. DEFT endeavors were deliberately organized with a win-win mindset for DUSON and DUHS.

With any new projects, pilot implementation is an important preliminary step toward identifying and improving inaccurate assumptions and inefficient processes. This preliminary testing will also afford the “outside” team an opportunity to get acculturated with the hospital workflow processes, resources, and environment. This is relevant as any new hospital program will need to align its goals and outcomes with the hospital's strategic priorities. Additionally, hospital leaders are often wary about costs associated with new services, thus sustainability discussions will have to involve program data to showcase an acceptable return on investment. For DEFT, the team intends to perform cost-effectiveness analyses that take into consideration its annual budget versus potential revenues including savings associated with reduction in readmissions (if any).

As a result of this pilot implementation, our team learned several important lessons that need to be addressed before we scale up the program. Of the 104 consult orders we received, the discharge disposition of 16 patients changed from home to skilled nursing facility after the caregivers had already consented to participate in the training. This may suggest that the consult orders were made too early before discharge decisions were finalized. A caveat, however, is that if consult orders were made too late or on the day of discharge, contacting the caregiver and scheduling a face-to-face training would not be possible. Thus, further discussions around optimal timing of placing consult orders are needed.

The first version of the DEFT consult template required the providers to enter caregiver information, including caregiver's contact phone number. However, providers often faced difficulty in obtaining caregiver information as caregivers were frequently not at the bedside during clinical rounds. Many providers stated that more consults could be made if caregiver phone number was optional. As a response, we modified this requirement and opted to use next-of-kin information on the medical record as an avenue for obtaining caregiver contact information.

During the first three months of our pilot study, we presented our program to various groups of medical learners (i.e., interns, residents, fellows) only to discover that these learners were only in the unit for a short time because of the nature of their clinical rotation. To reduce workload associated with repeated presentations, we decided to focus our efforts on medical directors, staff nurses, and case managers who were permanently assigned to a unit. We then requested that these permanent providers share the DEFT information with their respective learners.

In the preliminary study, the DEFT team contacted each caregiver by phone immediately upon receipt of the consult order. In addition to describing the DEFT program and scheduling a training session if a caregiver was interested in participating, the caregiver survey was also completed by phone. However, this proved to be quite taxing for caregivers, as it often took about 15-20 minutes to complete the assessment. Additionally, because the protocol required a completed survey before a caregiver could participate in the training, an incomplete caregiver survey meant no scheduled training for the caregiver. To address this issue, the DEFT team reconfigured the mode of assessment to a paper survey, which was to be completed during the in-person training. Caregivers acknowledged that completing written questionnaires and surveys in person was easier and quicker than being asked to respond to each item over the phone.

In the early phase of the pilot, the DEFT trainers mostly led the discussions in training sessions. However, this tactic often resulted in passive learning with caregivers doing more listening than talking. Therefore, the DEFT trainers revised their teaching approach to follow a more conversational flow with the dictum of “less is more” and an emphasis toward practical strategies. For instance, instead of going over risk factors for falls, a photo of a cluttered room was presented. Caregivers were asked to identify items in the photo that could contribute to falls. Each caregiver was also asked to reflect and describe the layout of furniture in the patient's bedroom at home and share one to two strategies for improving it. This conversational approach allowed the DEFT team to tailor information based on the caregiver's baseline knowledge and input. Lastly, the training site was originally scheduled at the DUSON, a 15-minute walk from DUH, where state-of-the-art technology such as mannequins and simulations can be used. However, an overwhelming majority of caregivers were reluctant to leave the hospital and opted to have the training in a hospital classroom to stay close to their loved ones.

There were several limitations to our feasibility program. The DEFT program is based on an existing academic-practice partnership. Many hospitals, especially those located in rural areas, do not have academic affiliations. Thus, the DEFT workflow may not be feasible in these hospitals. Additionally, the DEFT workflow process relies on the use of an electronic medical record. Therefore, the communication pathways established by the DEFT team using the EMR are limited to hospitals with the same capability. Lastly, the two pilot units were selected based on existing collaborating relationships between the DEFT center director and physician leads of the two units. Other units where no previous collaboration has been established may not be as receptive to DEFT.

In summary, our pilot study demonstrated that implementing a caregiver training and support program in an academic medical center is feasible and has the potential to produce favorable caregiver and patient outcomes. Findings from the pilot study have given us directions on how to improve our existing processes before we plan for a wider-scale implementation.