Caregiver Engagement During Care Transition Cuts Hospital Readmission

Transitioning patients from one setting to another is an especially vulnerable time that can result in adverse effects. According to new data, caregiver engagement across healthcare transitions of chronically ill adults is integral to preventing hospital readmission, leading to better patient outcomes.

The meta-analysis of 54 studies involving over 31,000 patients added evidence proving the value of caregivers and their support to patients following discharge.

When the care team actively partners with caregivers in not only needs assessments and education prior to discharge, but also telemedicine follow-up post-discharge, care teams can improve care coordination, the press release stated.

As adults age with chronic illness, negative changes in health status may result in frequent and often sudden transitions across healthcare settings, such as from home to hospital and back to home or to a skilled nursing facility. On average, older adults will experience between two and five healthcare transitions in the year following a hospitalization.

But the analysis showed this isn’t always happening. Of the care transitions analyzed, only about half (49 percent) included caregiver engagement, the researchers said. The ones that included caregiver engagement yielded better clinical outcomes like lower hospital readmission or rehospitalization rates.

“In my own clinical practice, I have had multiple experiences of caregivers coming to me after a healthcare crisis of their loved ones to reflect on how they didn’t feel adequately prepared to support their loved ones’ care,” Kristin Levoy, PhD, MSN, RN, research scientist at Regenstrief Institute, said in a public statement. “These caregivers felt blindsided by how much care they had to provide and ill-equipped for the weighty healthcare decisions they were involved in.”

Despite caregivers holding a critical role in the patient experience, their needs are often overlooked, the study authors noted. When caregivers are not provided with necessary resources, they cannot provide the proper support and care to patients.

An unrelated 2018 study noted that about 70 percent of family caregivers feel ill-prepared for the job, underscoring a need for family engagement and support. In addition, the survey found that the demands of caring for a sick or aging family member are taking an emotional toll on caregivers. Fifty-three percent of family caregivers said they have high levels of stress. 

“Caregivers play a critical role in enhancing patient outcomes and we can do a better job of supporting these unrecognized members of the healthcare team,” Levoy, who is also an assistant professor at Indiana University School of Nursing, explained. “Caregivers often feel abandoned, particularly in times of healthcare crises, like an unexpected hospitalization, and we need to set them up for success, which includes addressing their unique needs. And these needs only grow greater as the chronic illness advances and the patient’s disease and treatment complexity increases.”

Ensuring that caregivers are well-informed and trained makes them more likely to fulfill responsibilities and provide appropriate post-discharge care that can help avoid re-hospitalizations.

Studies have shown that patients with a strong social support presence are more likely to comply with their self-management plans and engage in healthy behaviors.

“Increasing support for caregiver engagement during care transitions may require the development of value-based reimbursement models that reward health care systems for the adoption of caregiver-engaged principles, creating an environment for systemic change in the way healthcare systems conduct business, which may also increase the capability of caregivers to provide care in the home over time, thus, delaying institutionalization,” the study authors stated.

“Whether in research or clinical practice, transitional care should not be conducted without careful consideration of where and how caregivers will be incorporated and supported as active partners in optimizing patient care across health care transitions.”

Since family caregiver engagement is seen as such an integral part of the care experience, the healthcare industry has been looking at ways to increase participation.

Some states have even enforced family engagement through law.

The Ohio Caregiving Act proposed by AARP Ohio requires hospitals to train and engage family caregivers in at-home patient care, easing the transition during hospital discharge.

Representative Sarah LaTourette, another law co-sponsor, explained that this bill will drive patient safety in the discharge and at-home care process. Family members are already providing care for their patients, LaTourette said. Driving family caregiver engagement will make this practice even safer and more efficient.