MODELS OF GERIATRIC CARE, QUALITY IMPROVEMENT, AND PROGRAM DISSEMINATION
Testing a Family-Centered Intervention to Promote Functional and Cognitive Recovery in Hospitalized Older Adults Marie Boltz, PhD, CRNP,* Barbara Resnick, PhD, CRNP,† Tracy Chippendale, PhD, OTR/L,‡ and James Galvin, MD, MPH§
A comparative trial using a repeated-measures design was designed to evaluate the feasibility and outcomes of the Family-Centered Function-Focused-Care (Fam-FFC) intervention, which is intended to promote functional recovery in hospitalized older adults. A family-centered resource nurse and a facility champion implemented a three-component intervention (environmental assessment and modification, staff education, individual and family education and partnership in care planning with follow-up after hospitalization for an acute illness). Control units were exposed to function-focused-care education only. Ninetyseven dyads of medical patients aged 65 and older and family caregivers (FCGs) were recruited from three medical units of a community teaching hospital. Fifty-three percent of patients were female, 89% were white, 51% were married, and 40% were widowed, and they had a mean age of 80.8 7.5. Seventy-eight percent of FCGs were married, 34% were daughters, 31% were female spouses or partners, and 38% were aged 46 to 65. Patient outcomes included functional outcomes (activities of daily living (ADLs), walking performance, gait, balance) and delirium severity and duration. FCG outcomes included preparedness for caregiving, anxiety, depression, role strain, and mutuality. The intervention group demonstrated less severity and shorter duration of delirium and better ADL and walking performance but not better gait and balance performance than the control group. FCGs who participated in Fam-FFC showed a significant increase in preparedness for caregiving and a decrease in anxiety and depression from admission to 2 months after
From the *William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts; †School of Nursing, University of Maryland, Baltimore, Maryland; ‡Department of Occupational Therapy, Steinhardt School of Culture, Education and Human Development, New York University, New York, New York; and §Langone School of Medicine, New York University, New York, New York. Address correspondence to Marie Boltz, William F. Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Chestnut Hill, MA 02467. E-mail: [email protected] DOI: 10.1111/jgs.13139
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discharge but no significant differences in strain or quality of the relationship with the care recipient from FCGs in the control group. Fam-FFC is feasible and has the potential to improve outcomes for hospitalized older adults and their caregivers. J Am Geriatr Soc 62:2398–2407, 2014.
Key words: function-focused care; transitions; family centered
H
ospitalization-associated disability (HAD), manifesting as a decrease in the ability to complete the basic activities of daily living (ADLs) needed to live independently (bathing, dressing, rising from bed or a chair, using the toilet, eating, walking across a room, using stairs)1 occurs in 35% to 50% of hospitalized individuals aged 70 and older.2 It is associated with longer hospital stays and adverse discharge outcomes, including unplanned hospital readmissions,3 dependence on family members, discharge to a nursing home, and mortality.1 Risk factors for HAD include older age,4 depression,5 cognitive impairment,6,7 limited social contact,7 the presence of a pressure ulcer,7 preadmission ADL limitations,6 and impaired mobility at baseline.8 Delirium, present at admission8 or hospital acquired,9 is associated with functional decline that often persists after hospitalization.10 Hospital settings, which focus on correcting the acute admitting problem, are not designed clinically and operationally to support the goal of helping elderly adults regain or improve functionality and resume their roles, routines, or pre-illness activities.11 A function-focused care philosophy has been used successfully to optimize function and physical activity in residents in long-term care settings,12,13 but it has not been sufficiently incorporated into acute care units. FFC is a philosophy of care wherein physical activity and self-care approaches are incorporated into routine care and rehabilitation therapy. Although older adults
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themselves place a high priority on functional independence,11 engagement in self-care and physical activity remains limited during hospital stays14–21 and may be more difficult in older adults with cognitive and functional impairments.
THE FAMILY CAREGIVER ROLE DURING HOSPITALIZATION Family caregivers (FCGs) can exert considerable influence over the delivery of care to older adults, including the older adult’s activity level. For example, older adults are more likely to engage in self-care and walking programs when families encourage and advocate for them to do so,16 but lack of understanding of the ramifications of inactivity and how to prevent deconditioning and functional loss may cause families to attempt to restrict physical activity. FCGs may believe that bedrest will promote recovery from an acute illness or fear that the older adult will fall if physical activity is encouraged.15,16 Furthermore, lack of information and limited engagement with care decisions is common22 and encumber the FCG’s efforts to advocate for the older adult to be involved in physical activity, cognitive stimulation, and self-care.15 Thus, interventions that support the role of FCGs in the functional recovery of hospitalized older adults warrant attention. Hospitalization may provide respite for some FCGs. Conversely, during periods of acute illness, FCGs often experience strain, anxiety, depression, and stress in their relationship with the care recipient.22,23 Although FCGs provide healthcare providers with vital information about health, baseline function, and response to treatment,23 little research has examined the role of family members in the assessment and care planning processes in the acute care setting. In a previous study,24 a two-session educational program decreased FCGs’ role strain, and they reported that they were better prepared to provide care. Although patient outcomes (cognition, functional status) were inconclusive, this research, similar to prior research in children25 and older adults,26 demonstrated the feasibility of providing education to families and actively including them in decision-making. Weaknesses of these prior studies included lack of consideration of organizational factors that are known to significantly influence care processes and outcomes for older adults. Geriatric models of care, including Acute Care for the Elderly units and inpatient geriatric rehabilitation, have yielded good functional outcomes at discharge,27,28 and the Hospital Elder Life Program, a volunteer-intensive interdisciplinary delirium-prevention intervention, has demonstrated good delirium outcomes,29 but these interventions have not generally focused on postacute care to support return to maximum or baseline function. Models of discharge planning30 and transitional care31,32 have been shown to be effective in preventing rehospitalization and reducing length of stay in hospitalized older adults but have not focused on functional outcomes33 or emphasized early involvement of FCGs. To limit HAD and promote the best possible postdischarge outcomes, Family-Centered Function-Focused Care (Fam-FFC) an educational and empowerment model initiated within a prepared care
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environment, was developed. Fam-FFC begins at admission to the hospital and continues through the 60-day postacute period, supporting FCG, patient, and staff efforts to promote functional recovery. The first aim of this study was to test the feasibility of Fam-FFC. The second aim was to examine the effect of Fam-FFC on functional outcomes of hospitalized older medical patients. It was hypothesized that hospitalized older adults who were exposed to Fam-FFC would have less severity and shorter duration of delirium and better physical function (ADL performance, walking performance, gait, balance) than those who receive FFC education only evaluated at discharge and 14 and 60 days after discharge. It was also hypothesized that hospitalized PWD who were exposed to Fam-FFC would use fewer postacute rehabilitation services; have shorter hospital stays, fewer discharges to nursing home, less recidivism (readmission to the hospital within 30 days for the acute admitting problem), and less postacute delirium; and be more likely return to prehospitalization (2 weeks before admission) ADL performance 60 days after discharge. The third study aim was to examine the effect of Fam-FFC on FCG preparedness for caregiving, affective status (anxiety, depression), role strain, and relationship with the patient. It was hypothesized that FCGs exposed to Fam-FFC would feel that they were better prepared for caregiving, less anxious, and less depressed and have less role strain and a better relationship with the patient at discharge and 14 and 60 days after discharge.
THEORETICAL FRAMEWORK The Fam-FFC intervention that was focused on outcomes for the patient was developed using a social ecological framework that acknowledges the intrapersonal, interpersonal, environmental, and policy factors that influence functional outcomes.34 This framework has guided other studies in settings that have addressed the organizational factors affecting the delivery of and response to functionfocused care.12,13 The aspects of the intervention focused on the FCG was guided using self-regulation theory.35 Specifically, Fam-FFC recognizes that the FCG can serve as an invaluable resource to promote the patient’s engagement in function and physical activity. Self-regulation theory35 offers the theoretical perspective that the FCG’s understanding of the patient’s condition, particularly with regard to such things as function and delirium, will strengthen the coping abilities of the FCG and, in turn, the affective response of the FCG through the acute illness that the care recipient experiences.24 Effective support of the FCG role (through information, education, and engagement in decision-making) is associated with greater role preparedness; better quality of relationship with care recipient (mutuality), and less perceived difficulty in performing a role (role strain).36
METHODS Design This study used a comparative repeated-measures design in three medical units of a community teaching hospital in
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the northeast United States. The units were matched based on size, staffing, and physical configuration. One unit served as the intervention unit, and two units served as control units. Two control units were used to facilitate equal recruitment between the control and intervention arms.
Recruitment and Consent The research evaluator provided study information to patients and FCGs within 24 hours of admission to the unit. If the patient and FCG agreed to the study, the Evaluation to Sign Consent (ESC) form37 was used to determine ability to sign consent. Patients who were unable to pass the ESC but were able to provide assent were enrolled when their legally authorized representative provided consent. Patient eligibility included aged 65 and older and English-speaking and reading. Patients who were known to be terminally ill or receiving hospice care or surgery were excluded. Family members aged 21 and older whose relatives met inclusion criteria were eligible if they could speak and read English; were related to the patient by blood, marriage, adoption, or affinity as a significant other; and were primary FCGs who lived with the patient or provided caregiving from an alternate residence. The institutional review boards of the New York University School of Medicine and the study site approved the study.
Sample Of the 502 patients screened, reasons for ineligibility included unavailability within 24 hours of admission because of tests scheduled (n = 31), terminal illness or hospice enrollment (n = 45), family members who did not respond to call (n = 3), and inability to understand English (n = 2). Of the 421 eligible patient–family dyads who were informed about the purpose of the study and invited to participate, 100 (24%) agreed to participate. The reasons for not participating in the study included refusal because of patient fatigue or other symptoms (n = 147); FCG fatigue or lack of interest (n = 133); and patient not wanting to burden the FCG with study involvement (n = 41). Two patients elected to drop out of the study, and one died during the hospitalization. Ninety-seven dyads, 47 from the control units and 50 from the intervention unit, constituted the final enrolled sample. Two patients were lost to follow-up between 2 weeks and 2 months after discharge, yielding 46 in the final control arm and 49 in the final intervention arm.
Implementation of the Intervention The Fam-FFC intervention aims to create an enabling care environment that engages patients and FCGs in a plan for functional recovery. A family-centered resource nurse (FCRN), a registered nurse, devoted 10 hours a week to implement the Fam-FFC intervention with the support of the research team. The FCRN was experienced in acute care of older adults and certified in gerontology. To support implementation and sustainability of the intervention, the study site appointed a nursing supervisor as the unit champion to work with the FCRN. The FCRN, with the support
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of the unit champion, implemented the components of Fam-FFC described in Table 1. Components I (Environmental and Policy Evaluation) and II (Staff Education) were initiated with the nursing staff before Component III (FamCare) to establish readiness. These components continued throughout the course of the intervention and overlapped with the FamCare component (FCG/patient education, jointly developed bedside goals and treatment plans, and postacute follow-up). The control units received function-focused care education on a modified version of the staff education component, as described in Table 1.
Measures Descriptive Measures Descriptive information was collected on patient age, race, sex, education, marital status, type of residence before hospitalization, and use of a mobility device. Cognitive impairment, delirium, and comorbidity upon admission were measured using the Mini-Cog,38 Confusion Assessment Method,39 and Charlson Comorbidity Index40 respectively. Information was also collected on baseline physical function (self- or FCG report of status 2 weeks before admission) using the Barthel Index, a 14-item measure of self-care performance.41 For family members, information was collected on age, race, sex, education, marital status, work status, and role in the family (spouse, child, other). All measures have established evidence of reliability and validity for use with older adults and FCGs, as noted below.
Patient Outcome Measures Information was collected on the patient outcome measures ADL performance, walking performance, gait, balance, and delirium severity at admission, discharge, and 14 and 60 days after discharge. ADL performance measured using the Barthel Index41 from the oral report of the assigned nurse was obtained during the day of data collection. The single item from the Barthel Index that measures ability to walk 50 feet was used to measure walking performance. Gait and balance was measured using the Tinetti Scale,42 which consists of 12 items evaluating gait and 16 items evaluating balance. The severity of delirium was evaluated using the Delirium Rating Scale,43 a 10-item scale that ranges from 0 (no delirium) to 32 (highest degree of severity).
FCG Measures Outcome measures for FCGs were collected within 48 hours of patient admission to the unit, within 48 hours of discharge, and 14 and 60 days after discharge using pen-and-paper questionnaires. Preparedness for caregiving was evaluated using the Preparedness for Caregiving Scale, an eight-item self-rated instrument that asks caregivers how well prepared they believe they are for multiple domains of caregiving such as providing physical care and emotional support, setting up in-home support services, and managing the stress of caregiving. Items are rated 0 (not at all prepared) to 4 (very well prepared); scores range from 0 to 32.36,44 Anxiety was evaluated using the
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Table 1. Description of Family-Centered, Function-Focused Care (Fam-FFC) Intervention Component
Person Responsible
When Delivered
Recipient
Description
Environmental and policy evaluation
FCRN
Months 1, 3, and 9
Intervention unit
Staff education
FCRN and unit champion
Month 1
Nursing staff on intervention and nonintervention units
FamCare
FCRN
Months 2, 3, and 5
Nursing staff on intervention unit
Months 2–10
FCG and patients on intervention unit
Assessment and modification as needed of lighting, pathway clearance, seating, bed height, toilet height, access to and storage of sensory and mobility aids Shift report that includes patient and family Bedside write boards to facilitate communication and storage of care plans Educational sessions addressing causes, prevention, and management of functional decline and delirium Assessment of cognition, mood, function (capability and performance) Evaluation of patient and family preferences and needs Incorporating function-focused care into routine activities Communication with patients and families including motivating patientsa Methods of partnering with FCGs (active listening, information sharing, care planning, promoting advocacy and patient and family engagement in decision-making)a Discharge preparationa Educational reminders of important educational points provided in staff mailboxes and posted on educational board of intervention unit Information on admitting condition, diagnostics, and treatment Family and patient education addressing: o Rationale for interdisciplinary interventions to prevent delirium and functional decline (e.g., avoiding high-risk medications and encouraging mobility): o Techniques the FCG could employ (e.g., encouraging and motivating self-care and physical activity, supporting cognitive and social engagement to support return to normal roles and routines, help with meals): o Discharge checklist (e.g., follow-up care for acute admitting problem as well as function-focused care—physical activity and routine, social engagement, cognitive stimulation) Systematic inclusion of FCG and patient in: o Assessment (including baseline cognition and physical function): o Jointly developed bedside goals and care plans that support functional recovery and prevention of complications (communication, mobility and physical activity, self-care, cognitive stimulation, nutrition, sleep, appropriate medication use, comfort measures, anxiety relief), updated daily with assigned nursing staff, FCG, and patient Collaboration emphasized with other disciplines, including rehabilitation: o Plans that delineate FCG involvement in care: o Discharge teaching and planning incorporating functionfocused care dimensions in addition to management of medical condition Postacute follow-up by FCRN to provide ongoing education and modification of the function-focused care plan through: o Home visit within 48 hours of discharge: o Weekly telephone calls for 4 weeks: o Coaching the patient and FCG to collaborate with postacute providers
FCRN = family-centered resource nurse; FCG = family caregiver. a Not included in nonintervention unit education.
seven-item Hospital Anxiety and Depression Scale (HADS) subscale for Anxiety (HADS-A), and depression was assessed using the seven-item HADS subscale for Depression (HADS-D).45,46 Scores are categorized as normal
(0–7), mild (8–10), moderate (11–14), severe (15–21) for each of the HADS subscales and range from 0 to 21. Mutuality, defined as the positive quality of the relationship between caregiver and care receiver and the
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ability of the caregiver to find meaning in the caregiving situation, was measured using the Mutuality Scale,36,44 which includes dimensions of reciprocity, love, shared pleasurable activities, and shared values.36 Fifteen items are rated on a 5-point scale that ranges from 0 (not at all) to 4 (a great deal); scores range from 0 to 60 (high mutuality).36,44 Caregiver strain was evaluated using the modified Caregiver Strain Index (CSI), a 13-question tool that measures strain related to the following domains that affect caregiving: employment, financial, physical, social and time.47,48 A bedside log was used to detail FCG involvement in care according to type of activity and time spent.
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tion was violated, the Greenhouse-Geisser F-test was used when drawing conclusions regarding the time-bytreatment interaction effect. Post hoc analyses were conducted using the Bonferroni correction when preceded by significant analysis of variance effects. ANOVA was used to compare length of hospital stay in treatment groups. Chi-square analysis was used to compare treatment differences in patients with regard to the number of new admissions to nursing homes upon hospital discharge, unplanned hospital readmissions within 30 days of discharge, return to baseline function, and delirium 2 months after discharge.
RESULTS Data analysis Descriptive analysis of the data according to intervention arm was performed to assess for differences in demographic and baseline variables. Correlations between sample characteristics and outcome variables were examined to identify potential covariates. A two (group) by four (time) repeated-measures analysis of variance (ANOVA) was used, with patient and family study outcomes as the dependent variable. Scatterplots, frequencies, and boxplots were evaluated to assess model assumptions for each outcome. The Mauchly test was used to evaluate sphericity. When the sphericity assump-
Patient Characteristics Table 2 reports patient and FCG characteristics. Fiftythree percent of patients were female, 89% were white, 51% were married, and 40% were widowed. Patients had a mean age of 80.8 7.5. Thirty–three percent were college educated; 95% were admitted from a private residence and the rest from assisted living. Mean self-reported preadmission Barthel Index (2 weeks before admission) was 91.1 17.0, and 43% used an assistive device for mobility. Upon admission, 52% had cognitive impairment and 25% delirium, and 29% reported frequently feeling
Table 2. Participant and Family Caregiver Characteristics Characteristic
Patient Female, n (%) White, n (%) Married, n (%) College graduate, n (%) Admitted from private residence, n (%) Cognitively impaired, n (%) Delirium at admission, n (%) Depressed, n (%) Use of mobility device, n (%) Persistent pain, n (%) Age, meanSD Charlson Comorbidity Index, mean SD Preadmission Barthel Index, mean SD Family caregiver, n (%) Relationship to patient Wife Husband Daughter Son Other White Married College graduate Age 31–45 46–65 66–79 ≥80 Employed outside the home SD = standard deviation.
Total, N = 97
Nonintervention Group, n = 47
Intervention Group, n = 50
P-Value
51 (53) 86 (89) 49 (51) 31 (33) 92 (95) 50 (52) 24 (25) 28 (29) 42 (43) 47 (48) 80.6 7.9 3.4 2.5 91.1 17.0
29 (62) 41(87) 24 (50) 14 (30) 45 (96) 26 (55) 12 (26) 13 (28) 20 (43) 24 (51) 79.5 8.1 3.3 2.7 89.3 20.7
22 (44) 45 (90) 25 (50) 17 (34) 47 (94) 24 (48) 12 (24) 15 (30) 22 (44) 23 (46) 82.2 6.7 3.5 2.3 92.8 12.9
.08 .16 .37 .32 .84 .47 .86 .47 .89 .62 .07 .79 .32
30 (31) 15 (15) 33 (34) 8 (8) 11(11) 86 (89) 76 (78) 40 (41)
11 (23) 12 (26) 17 (36) 1 (2) 6 (13) 41(87) 36 (76) 21 (45)
19 (38) 3 (6) 16 (32) 7 (14) 5 (10) 45 (90) 40 (80) 19 (38)
9 (9) 37 (38) 32 (33) 19 (20) 52 (54)
6 (13) 15 (32) 16 (34) 10 (21) 27 (57)
3 (6) 22 (44) 16 (32) 9 (18) 25 (50)
.02
.16 .31 .81 .48
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sad or depressed. Average Charlson Comorbidity Index was 3.4 2.5. There were no significant differences between the groups in patient characteristics.
FCG Characteristics Thirty-four percent of FCGs were daughters, and 31% were female spouses or partners; 78% were married, and 42% had a college education or more. Thirty-eight percent of FCGs were aged 46 to 65, and 54% were employed outside the home. The only significant difference between the treatment groups was the role relationship between the patient and FCG (P = .02). FCGs were more likely to be wives and sons in the intervention group and husbands in the control group. Role relationship was significantly correlated to FCG strain at all time points and was controlled for in the analysis.
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no significant effect of the intervention on gait and balance (F (1.4) = 1.9, P = .17). Discharge outcomes are shown in Table 4. The average hospital length of stay did not differ significantly between the intervention (5.1 3.0) and control (5.9 7.7) groups. There was no significant difference in the number of patients using postacute rehabilitation services or transferred to a nursing home. There was a modest treatment effect on the number of 30-day hospital readmissions, which was lower in the treatment group (n = 7, 14%) than in the control group (chi-square = 6.4, P = .01). Patients exposed to Fam-FFC had less delirium 2 months after discharge (chi-square = 4.5, P = .04), and significantly more patients returned to baseline ADL performance in the group exposed to Fam-FFC (chisquare = 9.7, P = .002).
FCG Outcomes Patient Outcomes Table 3 reports primary patient outcomes at discharge and 2 weeks and 2 months after discharge. There were no significant differences between the groups in outcome variables evaluated at admission. Repeated-measures ANOVA demonstrated that the intervention was associated with a significant decrease in overall delirium severity (F (1.3) = 3.5, P = .05). Post hoc tests revealed that the FamFFC arm had less-severe delirium from admission to all other time points. Patients who participated in Fam-FFC had better ADL performance (F (2.3) = 3.3, P = .03), with improvement evident 2 months after discharge. Mean walking performance differed significantly between intervention arms (F (2.5) = 3.6, P = .02); post hoc tests showed that Fam-FFC was associated with less decrease in walking performance 2 months after discharge. There was
The outcome variables for FCGs are presented in Table 5. There were no significant differences between the groups in FCG baseline assessments. The intervention was associated with a significant increase in preparedness for caregiving (F (2.6) = 4.4, P = .007); post hoc tests revealed that Fam-FFC was associated with an increase in preparation for caregiving from admission to 2 months after discharge. Mean FCG anxiety differed significantly between groups (F (1.9) = 9.4, P < .001). Fam-FFC was associated with less anxiety from admission to 2 months after discharge than in the control group. The percentage of FCGs experiencing anxiety increased from 16% at admission (n = 12) to 34% (n = 16) (P = .01) at discharge in the nonintervention group and decreased from 36% (n = 18) to 22% (n = 11) (P < .001) in the intervention group. Mean depression scores differed significantly between interven-
Table 3. Primary Participant Outcomes at Discharge and 2 Weeks and 2 Months After Discharge Nonintervention Outcome
Delirium severity (range 0–32) Admission Discharge 2 weeks 2 months Physical function Barthel Index (range 0–100) Admission Discharge 2 weeks 2 months Walking performance, 50 yards (range 0–15) Admission Discharge 2 weeks 2 months Gait and balance (range 0–28) Admission Discharge 2 weeks 2 months
Intervention
Mean Standard Deviation
4.4 4.7 2.6 2.4
7.4 6.9 3.5 3.2
82.2 79.3 78.8 81.2
25.7 25.4 27.7 27.4
81.6 81.7 84.8 91.2
21.7 23.0 19.6 15.2
11.2 10.8 11.0 9.1
5.6 5.4 5.5 5.0
12.9 12.1 12.0 12.0
4.1 4.9 5.2 4.9
20.2 20.1 19.8 20.2
8.1 8.0 8.5 8.1
21.0 19.1 19.6 20.1
13.5 8.6 8.6 8.0
F (Degrees of Freedom)
P-Value
3.5 (1.3)
.05
3.3 (2.3)
.03
3.6 (2.6)
.02
1.9 (1.4)
.24
4.5 7.2 1.7 2.3 0.76 1.30 0.82 0.81
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Table 4. Patient Discharge Outcomes Outcome
Nonintervention
Discharge to a nursing home, n (%) Use of postacute rehabilitation services, n (%) Readmission to hospital within 30 days, n (%) Delirium present 2 months after discharge, n (%) Failed to return to baseline function by 2 months after discharge, n (%) Length of stay, mean standard deviation
13 (28) 30 (64) 17 (36) 8 (17) 16 (34) 5.9 7.7
Intervention
Chi-Square
P-Value
2.3 4.0 6.4 4.5 9.7
.80 .68 .01 .04 .002 .49
9 (18) 29 (58) 7 (14) 2 (4) 4 (8) 5.1 3.0
Table 5. Family Caregiver (FCG) Outcomes at Discharge and 2 Weeks and 2 Months After Discharge Nonintervention Outcome
Preparedness for caregiving (range 0–32) Admission Discharge 2 weeks 2 months Affective status Anxiety (range 0–21) Admission Discharge 2 weeks 2 months Depression (range 0–21) Admission Discharge 2 weeks 2 months Role strain (range 0–26) Admission Discharge 2 weeks 2 months Mutuality (range 0–56) Admission Discharge 2 weeks 2 months
Intervention
Mean Standard Deviation
F (Degrees of Freedom)
23.6 22.4 23.9 23.7
7.0 7.8 7.4 7.0
21.9 23.6 23.2 25.2
8.0 7.0 7.2 7.0
5.6 5.6 6.0 6.2
3.3 3.8 4.8 5.3a
6.5 6.3 5.7 4.5
4.3 4.5 4.2 3.9b
3.2 3.5 4.1 4.0
2.8 2.0 3.8 3.9c
3.8 3.8 3.6 3.0
3.7 3.9 4.2 3.8d
4.5 5.1 5.8 4.7
4.8 5.5 5.1 5.0
5.1 5.8 5.0 4.9
5.2 6.0 4.8 4.7
48.3 48.2 45.5 45.3
12.3 12.4 15.3 15.8
49.9 48.2 49.1 49.4
10.7 13.7 10.9 10.7
P-Value
4.4 (2.6)
.007
9.4 (1.9)
Testing a Family-Centered Intervention to Promote Functional and Cognitive Recovery in Hospitalized Older Adults Marie Boltz, PhD, CRNP,* Barbara Resnick, PhD, CRNP,† Tracy Chippendale, PhD, OTR/L,‡ and James Galvin, MD, MPH§
A comparative trial using a repeated-measures design was designed to evaluate the feasibility and outcomes of the Family-Centered Function-Focused-Care (Fam-FFC) intervention, which is intended to promote functional recovery in hospitalized older adults. A family-centered resource nurse and a facility champion implemented a three-component intervention (environmental assessment and modification, staff education, individual and family education and partnership in care planning with follow-up after hospitalization for an acute illness). Control units were exposed to function-focused-care education only. Ninetyseven dyads of medical patients aged 65 and older and family caregivers (FCGs) were recruited from three medical units of a community teaching hospital. Fifty-three percent of patients were female, 89% were white, 51% were married, and 40% were widowed, and they had a mean age of 80.8 7.5. Seventy-eight percent of FCGs were married, 34% were daughters, 31% were female spouses or partners, and 38% were aged 46 to 65. Patient outcomes included functional outcomes (activities of daily living (ADLs), walking performance, gait, balance) and delirium severity and duration. FCG outcomes included preparedness for caregiving, anxiety, depression, role strain, and mutuality. The intervention group demonstrated less severity and shorter duration of delirium and better ADL and walking performance but not better gait and balance performance than the control group. FCGs who participated in Fam-FFC showed a significant increase in preparedness for caregiving and a decrease in anxiety and depression from admission to 2 months after
From the *William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts; †School of Nursing, University of Maryland, Baltimore, Maryland; ‡Department of Occupational Therapy, Steinhardt School of Culture, Education and Human Development, New York University, New York, New York; and §Langone School of Medicine, New York University, New York, New York. Address correspondence to Marie Boltz, William F. Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Chestnut Hill, MA 02467. E-mail: [email protected] DOI: 10.1111/jgs.13139
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discharge but no significant differences in strain or quality of the relationship with the care recipient from FCGs in the control group. Fam-FFC is feasible and has the potential to improve outcomes for hospitalized older adults and their caregivers. J Am Geriatr Soc 62:2398–2407, 2014.
Key words: function-focused care; transitions; family centered
H
ospitalization-associated disability (HAD), manifesting as a decrease in the ability to complete the basic activities of daily living (ADLs) needed to live independently (bathing, dressing, rising from bed or a chair, using the toilet, eating, walking across a room, using stairs)1 occurs in 35% to 50% of hospitalized individuals aged 70 and older.2 It is associated with longer hospital stays and adverse discharge outcomes, including unplanned hospital readmissions,3 dependence on family members, discharge to a nursing home, and mortality.1 Risk factors for HAD include older age,4 depression,5 cognitive impairment,6,7 limited social contact,7 the presence of a pressure ulcer,7 preadmission ADL limitations,6 and impaired mobility at baseline.8 Delirium, present at admission8 or hospital acquired,9 is associated with functional decline that often persists after hospitalization.10 Hospital settings, which focus on correcting the acute admitting problem, are not designed clinically and operationally to support the goal of helping elderly adults regain or improve functionality and resume their roles, routines, or pre-illness activities.11 A function-focused care philosophy has been used successfully to optimize function and physical activity in residents in long-term care settings,12,13 but it has not been sufficiently incorporated into acute care units. FFC is a philosophy of care wherein physical activity and self-care approaches are incorporated into routine care and rehabilitation therapy. Although older adults
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themselves place a high priority on functional independence,11 engagement in self-care and physical activity remains limited during hospital stays14–21 and may be more difficult in older adults with cognitive and functional impairments.
THE FAMILY CAREGIVER ROLE DURING HOSPITALIZATION Family caregivers (FCGs) can exert considerable influence over the delivery of care to older adults, including the older adult’s activity level. For example, older adults are more likely to engage in self-care and walking programs when families encourage and advocate for them to do so,16 but lack of understanding of the ramifications of inactivity and how to prevent deconditioning and functional loss may cause families to attempt to restrict physical activity. FCGs may believe that bedrest will promote recovery from an acute illness or fear that the older adult will fall if physical activity is encouraged.15,16 Furthermore, lack of information and limited engagement with care decisions is common22 and encumber the FCG’s efforts to advocate for the older adult to be involved in physical activity, cognitive stimulation, and self-care.15 Thus, interventions that support the role of FCGs in the functional recovery of hospitalized older adults warrant attention. Hospitalization may provide respite for some FCGs. Conversely, during periods of acute illness, FCGs often experience strain, anxiety, depression, and stress in their relationship with the care recipient.22,23 Although FCGs provide healthcare providers with vital information about health, baseline function, and response to treatment,23 little research has examined the role of family members in the assessment and care planning processes in the acute care setting. In a previous study,24 a two-session educational program decreased FCGs’ role strain, and they reported that they were better prepared to provide care. Although patient outcomes (cognition, functional status) were inconclusive, this research, similar to prior research in children25 and older adults,26 demonstrated the feasibility of providing education to families and actively including them in decision-making. Weaknesses of these prior studies included lack of consideration of organizational factors that are known to significantly influence care processes and outcomes for older adults. Geriatric models of care, including Acute Care for the Elderly units and inpatient geriatric rehabilitation, have yielded good functional outcomes at discharge,27,28 and the Hospital Elder Life Program, a volunteer-intensive interdisciplinary delirium-prevention intervention, has demonstrated good delirium outcomes,29 but these interventions have not generally focused on postacute care to support return to maximum or baseline function. Models of discharge planning30 and transitional care31,32 have been shown to be effective in preventing rehospitalization and reducing length of stay in hospitalized older adults but have not focused on functional outcomes33 or emphasized early involvement of FCGs. To limit HAD and promote the best possible postdischarge outcomes, Family-Centered Function-Focused Care (Fam-FFC) an educational and empowerment model initiated within a prepared care
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environment, was developed. Fam-FFC begins at admission to the hospital and continues through the 60-day postacute period, supporting FCG, patient, and staff efforts to promote functional recovery. The first aim of this study was to test the feasibility of Fam-FFC. The second aim was to examine the effect of Fam-FFC on functional outcomes of hospitalized older medical patients. It was hypothesized that hospitalized older adults who were exposed to Fam-FFC would have less severity and shorter duration of delirium and better physical function (ADL performance, walking performance, gait, balance) than those who receive FFC education only evaluated at discharge and 14 and 60 days after discharge. It was also hypothesized that hospitalized PWD who were exposed to Fam-FFC would use fewer postacute rehabilitation services; have shorter hospital stays, fewer discharges to nursing home, less recidivism (readmission to the hospital within 30 days for the acute admitting problem), and less postacute delirium; and be more likely return to prehospitalization (2 weeks before admission) ADL performance 60 days after discharge. The third study aim was to examine the effect of Fam-FFC on FCG preparedness for caregiving, affective status (anxiety, depression), role strain, and relationship with the patient. It was hypothesized that FCGs exposed to Fam-FFC would feel that they were better prepared for caregiving, less anxious, and less depressed and have less role strain and a better relationship with the patient at discharge and 14 and 60 days after discharge.
THEORETICAL FRAMEWORK The Fam-FFC intervention that was focused on outcomes for the patient was developed using a social ecological framework that acknowledges the intrapersonal, interpersonal, environmental, and policy factors that influence functional outcomes.34 This framework has guided other studies in settings that have addressed the organizational factors affecting the delivery of and response to functionfocused care.12,13 The aspects of the intervention focused on the FCG was guided using self-regulation theory.35 Specifically, Fam-FFC recognizes that the FCG can serve as an invaluable resource to promote the patient’s engagement in function and physical activity. Self-regulation theory35 offers the theoretical perspective that the FCG’s understanding of the patient’s condition, particularly with regard to such things as function and delirium, will strengthen the coping abilities of the FCG and, in turn, the affective response of the FCG through the acute illness that the care recipient experiences.24 Effective support of the FCG role (through information, education, and engagement in decision-making) is associated with greater role preparedness; better quality of relationship with care recipient (mutuality), and less perceived difficulty in performing a role (role strain).36
METHODS Design This study used a comparative repeated-measures design in three medical units of a community teaching hospital in
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the northeast United States. The units were matched based on size, staffing, and physical configuration. One unit served as the intervention unit, and two units served as control units. Two control units were used to facilitate equal recruitment between the control and intervention arms.
Recruitment and Consent The research evaluator provided study information to patients and FCGs within 24 hours of admission to the unit. If the patient and FCG agreed to the study, the Evaluation to Sign Consent (ESC) form37 was used to determine ability to sign consent. Patients who were unable to pass the ESC but were able to provide assent were enrolled when their legally authorized representative provided consent. Patient eligibility included aged 65 and older and English-speaking and reading. Patients who were known to be terminally ill or receiving hospice care or surgery were excluded. Family members aged 21 and older whose relatives met inclusion criteria were eligible if they could speak and read English; were related to the patient by blood, marriage, adoption, or affinity as a significant other; and were primary FCGs who lived with the patient or provided caregiving from an alternate residence. The institutional review boards of the New York University School of Medicine and the study site approved the study.
Sample Of the 502 patients screened, reasons for ineligibility included unavailability within 24 hours of admission because of tests scheduled (n = 31), terminal illness or hospice enrollment (n = 45), family members who did not respond to call (n = 3), and inability to understand English (n = 2). Of the 421 eligible patient–family dyads who were informed about the purpose of the study and invited to participate, 100 (24%) agreed to participate. The reasons for not participating in the study included refusal because of patient fatigue or other symptoms (n = 147); FCG fatigue or lack of interest (n = 133); and patient not wanting to burden the FCG with study involvement (n = 41). Two patients elected to drop out of the study, and one died during the hospitalization. Ninety-seven dyads, 47 from the control units and 50 from the intervention unit, constituted the final enrolled sample. Two patients were lost to follow-up between 2 weeks and 2 months after discharge, yielding 46 in the final control arm and 49 in the final intervention arm.
Implementation of the Intervention The Fam-FFC intervention aims to create an enabling care environment that engages patients and FCGs in a plan for functional recovery. A family-centered resource nurse (FCRN), a registered nurse, devoted 10 hours a week to implement the Fam-FFC intervention with the support of the research team. The FCRN was experienced in acute care of older adults and certified in gerontology. To support implementation and sustainability of the intervention, the study site appointed a nursing supervisor as the unit champion to work with the FCRN. The FCRN, with the support
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of the unit champion, implemented the components of Fam-FFC described in Table 1. Components I (Environmental and Policy Evaluation) and II (Staff Education) were initiated with the nursing staff before Component III (FamCare) to establish readiness. These components continued throughout the course of the intervention and overlapped with the FamCare component (FCG/patient education, jointly developed bedside goals and treatment plans, and postacute follow-up). The control units received function-focused care education on a modified version of the staff education component, as described in Table 1.
Measures Descriptive Measures Descriptive information was collected on patient age, race, sex, education, marital status, type of residence before hospitalization, and use of a mobility device. Cognitive impairment, delirium, and comorbidity upon admission were measured using the Mini-Cog,38 Confusion Assessment Method,39 and Charlson Comorbidity Index40 respectively. Information was also collected on baseline physical function (self- or FCG report of status 2 weeks before admission) using the Barthel Index, a 14-item measure of self-care performance.41 For family members, information was collected on age, race, sex, education, marital status, work status, and role in the family (spouse, child, other). All measures have established evidence of reliability and validity for use with older adults and FCGs, as noted below.
Patient Outcome Measures Information was collected on the patient outcome measures ADL performance, walking performance, gait, balance, and delirium severity at admission, discharge, and 14 and 60 days after discharge. ADL performance measured using the Barthel Index41 from the oral report of the assigned nurse was obtained during the day of data collection. The single item from the Barthel Index that measures ability to walk 50 feet was used to measure walking performance. Gait and balance was measured using the Tinetti Scale,42 which consists of 12 items evaluating gait and 16 items evaluating balance. The severity of delirium was evaluated using the Delirium Rating Scale,43 a 10-item scale that ranges from 0 (no delirium) to 32 (highest degree of severity).
FCG Measures Outcome measures for FCGs were collected within 48 hours of patient admission to the unit, within 48 hours of discharge, and 14 and 60 days after discharge using pen-and-paper questionnaires. Preparedness for caregiving was evaluated using the Preparedness for Caregiving Scale, an eight-item self-rated instrument that asks caregivers how well prepared they believe they are for multiple domains of caregiving such as providing physical care and emotional support, setting up in-home support services, and managing the stress of caregiving. Items are rated 0 (not at all prepared) to 4 (very well prepared); scores range from 0 to 32.36,44 Anxiety was evaluated using the
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Table 1. Description of Family-Centered, Function-Focused Care (Fam-FFC) Intervention Component
Person Responsible
When Delivered
Recipient
Description
Environmental and policy evaluation
FCRN
Months 1, 3, and 9
Intervention unit
Staff education
FCRN and unit champion
Month 1
Nursing staff on intervention and nonintervention units
FamCare
FCRN
Months 2, 3, and 5
Nursing staff on intervention unit
Months 2–10
FCG and patients on intervention unit
Assessment and modification as needed of lighting, pathway clearance, seating, bed height, toilet height, access to and storage of sensory and mobility aids Shift report that includes patient and family Bedside write boards to facilitate communication and storage of care plans Educational sessions addressing causes, prevention, and management of functional decline and delirium Assessment of cognition, mood, function (capability and performance) Evaluation of patient and family preferences and needs Incorporating function-focused care into routine activities Communication with patients and families including motivating patientsa Methods of partnering with FCGs (active listening, information sharing, care planning, promoting advocacy and patient and family engagement in decision-making)a Discharge preparationa Educational reminders of important educational points provided in staff mailboxes and posted on educational board of intervention unit Information on admitting condition, diagnostics, and treatment Family and patient education addressing: o Rationale for interdisciplinary interventions to prevent delirium and functional decline (e.g., avoiding high-risk medications and encouraging mobility): o Techniques the FCG could employ (e.g., encouraging and motivating self-care and physical activity, supporting cognitive and social engagement to support return to normal roles and routines, help with meals): o Discharge checklist (e.g., follow-up care for acute admitting problem as well as function-focused care—physical activity and routine, social engagement, cognitive stimulation) Systematic inclusion of FCG and patient in: o Assessment (including baseline cognition and physical function): o Jointly developed bedside goals and care plans that support functional recovery and prevention of complications (communication, mobility and physical activity, self-care, cognitive stimulation, nutrition, sleep, appropriate medication use, comfort measures, anxiety relief), updated daily with assigned nursing staff, FCG, and patient Collaboration emphasized with other disciplines, including rehabilitation: o Plans that delineate FCG involvement in care: o Discharge teaching and planning incorporating functionfocused care dimensions in addition to management of medical condition Postacute follow-up by FCRN to provide ongoing education and modification of the function-focused care plan through: o Home visit within 48 hours of discharge: o Weekly telephone calls for 4 weeks: o Coaching the patient and FCG to collaborate with postacute providers
FCRN = family-centered resource nurse; FCG = family caregiver. a Not included in nonintervention unit education.
seven-item Hospital Anxiety and Depression Scale (HADS) subscale for Anxiety (HADS-A), and depression was assessed using the seven-item HADS subscale for Depression (HADS-D).45,46 Scores are categorized as normal
(0–7), mild (8–10), moderate (11–14), severe (15–21) for each of the HADS subscales and range from 0 to 21. Mutuality, defined as the positive quality of the relationship between caregiver and care receiver and the
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ability of the caregiver to find meaning in the caregiving situation, was measured using the Mutuality Scale,36,44 which includes dimensions of reciprocity, love, shared pleasurable activities, and shared values.36 Fifteen items are rated on a 5-point scale that ranges from 0 (not at all) to 4 (a great deal); scores range from 0 to 60 (high mutuality).36,44 Caregiver strain was evaluated using the modified Caregiver Strain Index (CSI), a 13-question tool that measures strain related to the following domains that affect caregiving: employment, financial, physical, social and time.47,48 A bedside log was used to detail FCG involvement in care according to type of activity and time spent.
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tion was violated, the Greenhouse-Geisser F-test was used when drawing conclusions regarding the time-bytreatment interaction effect. Post hoc analyses were conducted using the Bonferroni correction when preceded by significant analysis of variance effects. ANOVA was used to compare length of hospital stay in treatment groups. Chi-square analysis was used to compare treatment differences in patients with regard to the number of new admissions to nursing homes upon hospital discharge, unplanned hospital readmissions within 30 days of discharge, return to baseline function, and delirium 2 months after discharge.
RESULTS Data analysis Descriptive analysis of the data according to intervention arm was performed to assess for differences in demographic and baseline variables. Correlations between sample characteristics and outcome variables were examined to identify potential covariates. A two (group) by four (time) repeated-measures analysis of variance (ANOVA) was used, with patient and family study outcomes as the dependent variable. Scatterplots, frequencies, and boxplots were evaluated to assess model assumptions for each outcome. The Mauchly test was used to evaluate sphericity. When the sphericity assump-
Patient Characteristics Table 2 reports patient and FCG characteristics. Fiftythree percent of patients were female, 89% were white, 51% were married, and 40% were widowed. Patients had a mean age of 80.8 7.5. Thirty–three percent were college educated; 95% were admitted from a private residence and the rest from assisted living. Mean self-reported preadmission Barthel Index (2 weeks before admission) was 91.1 17.0, and 43% used an assistive device for mobility. Upon admission, 52% had cognitive impairment and 25% delirium, and 29% reported frequently feeling
Table 2. Participant and Family Caregiver Characteristics Characteristic
Patient Female, n (%) White, n (%) Married, n (%) College graduate, n (%) Admitted from private residence, n (%) Cognitively impaired, n (%) Delirium at admission, n (%) Depressed, n (%) Use of mobility device, n (%) Persistent pain, n (%) Age, meanSD Charlson Comorbidity Index, mean SD Preadmission Barthel Index, mean SD Family caregiver, n (%) Relationship to patient Wife Husband Daughter Son Other White Married College graduate Age 31–45 46–65 66–79 ≥80 Employed outside the home SD = standard deviation.
Total, N = 97
Nonintervention Group, n = 47
Intervention Group, n = 50
P-Value
51 (53) 86 (89) 49 (51) 31 (33) 92 (95) 50 (52) 24 (25) 28 (29) 42 (43) 47 (48) 80.6 7.9 3.4 2.5 91.1 17.0
29 (62) 41(87) 24 (50) 14 (30) 45 (96) 26 (55) 12 (26) 13 (28) 20 (43) 24 (51) 79.5 8.1 3.3 2.7 89.3 20.7
22 (44) 45 (90) 25 (50) 17 (34) 47 (94) 24 (48) 12 (24) 15 (30) 22 (44) 23 (46) 82.2 6.7 3.5 2.3 92.8 12.9
.08 .16 .37 .32 .84 .47 .86 .47 .89 .62 .07 .79 .32
30 (31) 15 (15) 33 (34) 8 (8) 11(11) 86 (89) 76 (78) 40 (41)
11 (23) 12 (26) 17 (36) 1 (2) 6 (13) 41(87) 36 (76) 21 (45)
19 (38) 3 (6) 16 (32) 7 (14) 5 (10) 45 (90) 40 (80) 19 (38)
9 (9) 37 (38) 32 (33) 19 (20) 52 (54)
6 (13) 15 (32) 16 (34) 10 (21) 27 (57)
3 (6) 22 (44) 16 (32) 9 (18) 25 (50)
.02
.16 .31 .81 .48
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sad or depressed. Average Charlson Comorbidity Index was 3.4 2.5. There were no significant differences between the groups in patient characteristics.
FCG Characteristics Thirty-four percent of FCGs were daughters, and 31% were female spouses or partners; 78% were married, and 42% had a college education or more. Thirty-eight percent of FCGs were aged 46 to 65, and 54% were employed outside the home. The only significant difference between the treatment groups was the role relationship between the patient and FCG (P = .02). FCGs were more likely to be wives and sons in the intervention group and husbands in the control group. Role relationship was significantly correlated to FCG strain at all time points and was controlled for in the analysis.
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no significant effect of the intervention on gait and balance (F (1.4) = 1.9, P = .17). Discharge outcomes are shown in Table 4. The average hospital length of stay did not differ significantly between the intervention (5.1 3.0) and control (5.9 7.7) groups. There was no significant difference in the number of patients using postacute rehabilitation services or transferred to a nursing home. There was a modest treatment effect on the number of 30-day hospital readmissions, which was lower in the treatment group (n = 7, 14%) than in the control group (chi-square = 6.4, P = .01). Patients exposed to Fam-FFC had less delirium 2 months after discharge (chi-square = 4.5, P = .04), and significantly more patients returned to baseline ADL performance in the group exposed to Fam-FFC (chisquare = 9.7, P = .002).
FCG Outcomes Patient Outcomes Table 3 reports primary patient outcomes at discharge and 2 weeks and 2 months after discharge. There were no significant differences between the groups in outcome variables evaluated at admission. Repeated-measures ANOVA demonstrated that the intervention was associated with a significant decrease in overall delirium severity (F (1.3) = 3.5, P = .05). Post hoc tests revealed that the FamFFC arm had less-severe delirium from admission to all other time points. Patients who participated in Fam-FFC had better ADL performance (F (2.3) = 3.3, P = .03), with improvement evident 2 months after discharge. Mean walking performance differed significantly between intervention arms (F (2.5) = 3.6, P = .02); post hoc tests showed that Fam-FFC was associated with less decrease in walking performance 2 months after discharge. There was
The outcome variables for FCGs are presented in Table 5. There were no significant differences between the groups in FCG baseline assessments. The intervention was associated with a significant increase in preparedness for caregiving (F (2.6) = 4.4, P = .007); post hoc tests revealed that Fam-FFC was associated with an increase in preparation for caregiving from admission to 2 months after discharge. Mean FCG anxiety differed significantly between groups (F (1.9) = 9.4, P < .001). Fam-FFC was associated with less anxiety from admission to 2 months after discharge than in the control group. The percentage of FCGs experiencing anxiety increased from 16% at admission (n = 12) to 34% (n = 16) (P = .01) at discharge in the nonintervention group and decreased from 36% (n = 18) to 22% (n = 11) (P < .001) in the intervention group. Mean depression scores differed significantly between interven-
Table 3. Primary Participant Outcomes at Discharge and 2 Weeks and 2 Months After Discharge Nonintervention Outcome
Delirium severity (range 0–32) Admission Discharge 2 weeks 2 months Physical function Barthel Index (range 0–100) Admission Discharge 2 weeks 2 months Walking performance, 50 yards (range 0–15) Admission Discharge 2 weeks 2 months Gait and balance (range 0–28) Admission Discharge 2 weeks 2 months
Intervention
Mean Standard Deviation
4.4 4.7 2.6 2.4
7.4 6.9 3.5 3.2
82.2 79.3 78.8 81.2
25.7 25.4 27.7 27.4
81.6 81.7 84.8 91.2
21.7 23.0 19.6 15.2
11.2 10.8 11.0 9.1
5.6 5.4 5.5 5.0
12.9 12.1 12.0 12.0
4.1 4.9 5.2 4.9
20.2 20.1 19.8 20.2
8.1 8.0 8.5 8.1
21.0 19.1 19.6 20.1
13.5 8.6 8.6 8.0
F (Degrees of Freedom)
P-Value
3.5 (1.3)
.05
3.3 (2.3)
.03
3.6 (2.6)
.02
1.9 (1.4)
.24
4.5 7.2 1.7 2.3 0.76 1.30 0.82 0.81
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Table 4. Patient Discharge Outcomes Outcome
Nonintervention
Discharge to a nursing home, n (%) Use of postacute rehabilitation services, n (%) Readmission to hospital within 30 days, n (%) Delirium present 2 months after discharge, n (%) Failed to return to baseline function by 2 months after discharge, n (%) Length of stay, mean standard deviation
13 (28) 30 (64) 17 (36) 8 (17) 16 (34) 5.9 7.7
Intervention
Chi-Square
P-Value
2.3 4.0 6.4 4.5 9.7
.80 .68 .01 .04 .002 .49
9 (18) 29 (58) 7 (14) 2 (4) 4 (8) 5.1 3.0
Table 5. Family Caregiver (FCG) Outcomes at Discharge and 2 Weeks and 2 Months After Discharge Nonintervention Outcome
Preparedness for caregiving (range 0–32) Admission Discharge 2 weeks 2 months Affective status Anxiety (range 0–21) Admission Discharge 2 weeks 2 months Depression (range 0–21) Admission Discharge 2 weeks 2 months Role strain (range 0–26) Admission Discharge 2 weeks 2 months Mutuality (range 0–56) Admission Discharge 2 weeks 2 months
Intervention
Mean Standard Deviation
F (Degrees of Freedom)
23.6 22.4 23.9 23.7
7.0 7.8 7.4 7.0
21.9 23.6 23.2 25.2
8.0 7.0 7.2 7.0
5.6 5.6 6.0 6.2
3.3 3.8 4.8 5.3a
6.5 6.3 5.7 4.5
4.3 4.5 4.2 3.9b
3.2 3.5 4.1 4.0
2.8 2.0 3.8 3.9c
3.8 3.8 3.6 3.0
3.7 3.9 4.2 3.8d
4.5 5.1 5.8 4.7
4.8 5.5 5.1 5.0
5.1 5.8 5.0 4.9
5.2 6.0 4.8 4.7
48.3 48.2 45.5 45.3
12.3 12.4 15.3 15.8
49.9 48.2 49.1 49.4
10.7 13.7 10.9 10.7
P-Value
4.4 (2.6)
.007
9.4 (1.9)
