The 1999 Millennium Act, which expanded coverage of Long Term Care for Veterans, stipulated that Veterans receive care in the least restrictive setting possible -- their homes. Even with home and community-based care (HCBC), Veterans rarely can remain in their homes without help from willing, qualified informal caregivers. To date, caregivers have little to no training about how to be caregivers. Half of VA caregivers report that they have not received training from a provider that they deemed necessary. Thus, a caregiver training program that increases skills and increases Veterans' days at home is directly relevant to VHA's needs and mission. Building upon past evidence, HI-FIVES is an innovative program that supports and trains informal caregivers of Veterans at the time Veterans are referred to home and community-based care, a critical moment in a Veteran's VHA health care use trajectory. Referral to HCBC is a time that caregivers may face personal strain and uncertainty about demands involved in caregiving. As such, it presents a teachable moment to train caregivers for the demands imposed by caregiving.
The objective is to examine the effectiveness of a caregiver skill training program, Helping Invested Families Improve Veterans Experiences Study (HI-FIVES).
We hypothesize that:
1) At 12 months post-treatment, Veterans with caregivers in the skill training program (HI-FIVES) will have clinically significant increases in days at home compared to Veterans in usual care. Days at home are defined as days not in emergency department, inpatient hospital, and post-acute care settings.
2) At 12 months post-treatment, Veterans with caregivers in the skill training program (HI-FIVES) will have significant reductions in total VA health care costs compared to Veterans in usual care.
3) Post-treatment, caregivers and Veterans with caregivers in the skill training program (HI-FIVES) will have significantly higher satisfaction with VHA health care compared to caregivers and Veterans in usual care.
4) Post-treatment, caregivers in the skill training program (HI-FIVES) will have clinically significantly lower depressive symptoms compared to caregivers in usual care.
This study is a randomized controlled trial of HI-FIVES, a 9-session individual and group-based skill training program for caregivers of functionally impaired Veterans who have been referred to receive HCBC. The 9 sessions of HI-FIVES include 3 tailored phone calls by a registered nurse, 4 group classes, and 2 additional tailored phone calls, occurring over 5 months total. Following consent and baseline assessments of the caregiver and the patient, caregivers were randomly assigned to one of two groups: HI-FIVES or usual care. Usual care members received information about the VA Caregiver Support Program supports and services (e.g. support line, web-site, contact information of the local Caregiver Support Coordinator), which is the standard of care for informal caregivers seeking resources in the VHA since the initiation of the VA Caregiver Support Program in 2011. All enrolled caregivers received information about VA Caregiver Support Program Services (e.g. HI-FIVES arm and usual care arm).
Caregivers' mean age was 61 years, 54% were Black, and 89% were female. Patients' mean age was 73 years, 53% were Black, and 96% were male. Two-thirds of caregivers were the Veterans' spouse; 20% were adult children. HI-FIVES intervention call completion was 96.9%, and group class attendance was 79.1%. HI-FIVES was associated with a clinically meaningful but not statistically significant 18% increase (95% CI 0.77, 1.79) in the rate of days at home, translating to a mean difference of 2.1 days over a year. No significant differences were observed in VHS health care costs at 12 months. Model-estimated mean baseline caregiver experience of VHS care (scale of 0-10) was 8.34 (95% CI: 8.10, 8.57); the modeled mean difference between HI-FIVES and controls at 3 months was 0.28 (p=.18); 0.53 (p<.001) at 6 months; and 0.46 (p=0.054) at 12 months. Model-estimated mean baseline patient experience of VHS care was 8.43 (95% CI 8.16, 8.70); the modeled mean difference between HI-FIVES and controls at 3 months was 0.29 (p=.27); 0.31 (p=0.26) at 6 months; and 0.48 (p=0.03) at 12 months. Model-estimated mean baseline caregiver CESD-10 was 8.96 (95% CI: 8.21, 9.72). No significant differences were observed in CESD-10 scores.
Skills training advances the caregiver and patient's perception of VHS care quality, and shows promise towards increasing the days a patient remains at home 12 months following the intervention. Skills training does not ameliorate caregiver depressive symptoms, thus other approaches are needed to clinically treat depression.
HI-FIVES skills training results increase our knowledge about how to improve caregiver and patient experience of VHS care. Intervention effects on the primary outcome are sensitive to the definition of nursing facility care (e.g. post-acute versus long-stay residential), thus clarity about intervention effects may arise from retesting the intervention in a larger sample.
- Colón-Emeric CS, Pieper CF, Van Houtven CH, Grubber JM, Lyles KW, Lafleur J, Adler RA. Limited Osteoporosis Screening Effectiveness Due to Low Treatment Rates in a National Sample of Older Men. Mayo Clinic proceedings. 2018 Dec 1; 93(12):1749-1759.
- Van Houtven CH, Oddone EZ, Hastings SN, Hendrix C, Olsen M, Neelon B, Lindquist J, Weidenbacher H, Boles J, Chapman J, Weinberger M. Helping Invested Families Improve Veterans' Experiences Study (HI-FIVES): study design and methodology. Contemporary clinical trials. 2014 Jul 1; 38(2):260-9.
- Smith V, Van Houtven CH. Comprehensive Support for Family Caregivers of Post-9/11 Veterans: Impact on Veteran Health Care Utilization and Costs. VIReC Partnered Research [Cyberseminar]. Health Services Research & Development. 2016 Sep 20.
- Van Houtven CH. Helping Invested Families Improve Veterans' Experiences Study (HI-FIVES): Briefing before the Operations and Policy Leadership of GEC; 2018 Aug 2; Washington, DC.
- Van Houtven CH. Identifying Caregivers: Challenges and Solutions from Implementation of iHI-FIVES within VHA: Briefing before the Operations and Policy Leadership of GEC; 2018 Aug 1; Washington, DC.
- Duan-Porter W, Van Houtven CH, Chapman J, Mahanna EP, Stechuchak KM, Coffman CJ, Hastings SN. Technology Use and Related Attitudes Among Veterans and Their Informal Caregivers. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.