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RRP 14-195 – HSR&D Study

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RRP 14-195
Caring for the Caregivers of Veterans: Planning a National Program Evaluation
Veronica Yank MD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: November 2014 - October 2015

BACKGROUND/RATIONALE:
Through the Caregivers and Veteran Omnibus Health Services Act of 2010, the VHA recognizes informal caregivers as providing essential care for Veterans with a wide array of serious chronic conditions. A national study of informal caregivers identified 66 million caregivers, and caregiver services were valued at $450 billion per year in 2009. To be effective, caregivers must be relatively healthy and not too disabled by their burden. Yet an estimated 30-45% of caregivers meet diagnostic criteria for major depression. Among caregivers of Veterans the burden of caregiving is even greater. In a 2010 national survey, they reported much higher rates of "high burden" caregiving and deleterious outcomes and their desire for skills and support to help with these burdens. The VA Caregiver Support Program (CSP) was formed to address these needs. It commissioned development and testing of Building Better Caregivers (BBC), a 6-week, interactive, online program designed to provide caregivers with skills and self-efficacy to perform effective caregiving and self-care, and with social support from peers and mentoring/modeling by peer-facilitators. Based on positive study findings, CSP began a national rollout of the BBC to all VA facilities in 2013. Since then, BBC has successfully reached only a small proportion of Veteran caregivers, and there has been wide variation across facilities in enrollment rates.

OBJECTIVE(S):
Study objectives are to:
Aim 1: Identify national and regional characteristics of BBC rollout
Aim 2: Identify facility characteristics associated with high versus low caregiver enrollment
Aim 3: Integrate findings, make recommendations, and design hybrid effectiveness-implementation trial to test BBC impact on key caregiver and Veteran sub-groups and strategies for optimizing implementation

METHODS:
We have evaluated the BBC rollout using the PARIHS framework. We performed semi-structured interviews with national (CSP) and regional (VISN lead) key informants, local VA staff (e.g., Caregiver Support Coordinators), and caregivers. Instruments probed for deeper understanding of BBC dissemination and related caregiver support activities. We coded interview data with descriptors for rollout characteristics that were successful versus unsuccessful. Descriptors were grouped to identify common themes. We also performed surveys with local staff and caregivers to enable triangulation with interview data.

FINDINGS/RESULTS:
We completed surveys and semi-structured interviews with caregivers (n=32) and interviews with local (n=13), regional (n=5), and national (n=4) VA staff involved in BBC rollout. Six percent (n=1265) of VA-registered family caregivers have enrolled in BBC (facility-level range 0% to 37%; median 5%). Among Veteran partners of surveyed caregivers (n=23; 72% response rate), 81% have >= 3 serious chronic conditions (e.g., post-traumatic stress disorder, traumatic brain injury, dementia). All surveyed caregivers reported suffering stress and other negative health effects as a result of becoming caregivers. Among the 43% enrolled in BBC, all would recommend it to other caregivers (even those that had not completed all six weeks of the class). Analysis of qualitative data from interviews with staff and caregivers identified a number of common themes on both strengths and weaknesses of the national BBC rollout:
(1) What has worked well (BBC rollout strengths)
- Positive feedback on BBC program from caregivers-meets goals
- Online interface convenient and easy for caregivers to use
- Successful outreach to some caregiver groups-used stories & multiple contacts, targets were caregivers of post-9/11 era Veterans
- Staff agreement about supportive research evidence, alignment with motivations & role, effective initial training, & useful resources
- Effective relationship between VA national leaders and vendor
(2) What is not working well (aspects that need to be improved upon)
- Some unmet caregiver preferences for class groupings & scheduling
- Ineffective outreach to some caregivers-e.g., of pre-9/11-era Veterans
- User technology not optimized-for outreach and referrals
- Potential partnerships not utilized-with community groups, VA services (primary care, mental health)
- Inadequate data management capabilities-for staff
- Unclear performance metrics-for staff
- Unmet needs for training and mentoring-for staff

IMPACT:
Findings will guide design of a hybrid effectiveness-implementation intervention trial that will compare strategies to assess BBC program impact on key caregiver and Veteran sub-groups and test strategies for optimizing BBC dissemination to thousands of Veterans who might benefit from improved family caregiving. They also can inform dissemination strategies for other national, web-based programs.

PUBLICATIONS:

Journal Articles

  1. Rosas LG, Lv N, Azar K, Xiao L, Yank V, Ma J. Applying the Pragmatic-Explanatory Continuum Indicator Summary Model in a Primary Care-Based Lifestyle Intervention Trial. American journal of preventive medicine. 2015 Sep 1; 49(3 Suppl 2):S208-14.
  2. Sink KM, Espeland MA, Castro CM, Church T, Cohen R, Dodson JA, Guralnik J, Hendrie HC, Jennings J, Katula J, Lopez OL, McDermott MM, Pahor M, Reid KF, Rushing J, Verghese J, Rapp S, Williamson JD, LIFE Study Investigators. Effect of a 24-Month Physical Activity Intervention vs Health Education on Cognitive Outcomes in Sedentary Older Adults: The LIFE Randomized Trial. JAMA. 2015 Aug 25; 314(8):781-90.
  3. Espeland MA, Newman AB, Sink K, Gill TM, King AC, Miller ME, Guralnik J, Katula J, Church T, Manini T, Reid KF, McDermott MM, LIFE Study Group. Associations Between Ankle-Brachial Index and Cognitive Function: Results From the Lifestyle Interventions and Independence for Elders Trial. Journal of The American Medical Directors Association. 2015 Aug 1; 16(8):682-9.
  4. Yank V, Tribett E, Green L, Pettis J. Learning from marketing: Rapid development of medication messages that engage patients. Patient education and counseling. 2015 Aug 1; 98(8):1025-34.
  5. Ma J, Yank V, Lv N, Goldhaber-Fiebert JD, Lewis MA, Kramer MK, Snowden MB, Rosas LG, Xiao L, Blonstein AC. Research aimed at improving both mood and weight (RAINBOW) in primary care: A type 1 hybrid design randomized controlled trial. Contemporary clinical trials. 2015 Jul 1; 43:260-78.
  6. Rejeski WJ, Rushing J, Guralnik JM, Ip EH, King AC, Manini TM, Marsh AP, McDermott MM, Fielding RA, Newman AB, Tudor-Locke C, Gill TM, LIFE Study Group. The MAT-sf: identifying risk for major mobility disability. The journals of gerontology. Series A, Biological sciences and medical sciences. 2015 May 1; 70(5):641-6.
  7. Rosas LG, Thiyagarajan S, Goldstein BA, Drieling RL, Romero PP, Ma J, Yank V, Stafford RS. The effectiveness of two community-based weight loss strategies among obese, low-income US Latinos. Journal of the Academy of Nutrition and Dietetics. 2015 Apr 1; 115(4):537-50.e2.
  8. Fitzgerald JD, Johnson L, Hire DG, Ambrosius WT, Anton SD, Dodson JA, Marsh AP, McDermott MM, Nocera JR, Tudor-Locke C, White DK, Yank V, Pahor M, Manini TM, Buford TW, LIFE Study Research Group. Association of objectively measured physical activity with cardiovascular risk in mobility-limited older adults. Journal of the American Heart Association. 2015 Feb 18; 4(2).
  9. Bann D, Hire D, Manini T, Cooper R, Botoseneanu A, McDermott MM, Pahor M, Glynn NW, Fielding R, King AC, Church T, Ambrosius WT, Gill TM, LIFE Study Group. Light Intensity physical activity and sedentary behavior in relation to body mass index and grip strength in older adults: cross-sectional findings from the Lifestyle Interventions and Independence for Elders (LIFE) study. PLoS ONE. 2015 Feb 3; 10(2):e0116058.
  10. Botoseneanu A, Ambrosius WT, Beavers DP, de Rekeneire N, Anton S, Church T, Folta SC, Goodpaster BH, King AC, Nicklas BJ, Spring B, Wang X, Gill TM, LIFE Study Groups. Prevalence of metabolic syndrome and its association with physical capacity, disability, and self-rated health in Lifestyle Interventions and Independence for Elders Study participants. Journal of the American Geriatrics Society. 2015 Feb 1; 63(2):222-32.
VA Cyberseminars

  1. Yank V. Evaluation of the national “Building Better Caregivers” (BBC) rollout: how research operations partnerships can optimize program tailoring, dissemination, and impact. VA HSR&D National Special Interest Group on Caregiving Research: Quarterly Webinar Series. [Cyberseminar]. 2015 Mar 24.


DRA: Aging, Older Veterans' Health and Care, Health Systems
DRE: none
Keywords: QUERI Implementation
MeSH Terms: none