Skip Navigation

Products For Patient Care

The CarePartner Program: Enhancing Caregiver Support for Heart Failure Patients

Objective

QUICCC investigators are developing and testing the feasibility of a system designed to enhance communication between patients with heart failure, their network of potential informal caregivers (e.g., adult children living outside of the home), and formal healthcare team. 

The system uses automated telephone assessment and behavior change calls with feedback to caregivers via e-mail and the Internet, along with a care manager portal and urgent clinical alerts delivered via e-mail, pager, and fax.

Development and Evaluation Plan

With funding from the Blue Cross and Blue Shield Foundation and the UMHS Institute for Gerontology, QUICCC investigators worked with cardiologists and general internists to develop the content for patient monitoring and self-care support calls.

In the pilot study, 50 heart failure patient-caregiver pairs were recruited from UMHS and the Ann Arbor VA. Patients completed automated assessments for up to 12 weeks, and both patients and caregivers provided feedback on their experience with system use. 

All system-generated e-mails, patient call attempts, assessment results, and clinician faxes were monitored by the research team.

Results of the Pilot: Patients completed 586 assessments (92% completion rate), and reported problems that may otherwise have gone unidentified. At follow-up, 75% of patients made changes in their self-care as a result of the intervention. The CP program may extend the impact of HF telemonitoring beyond what care management prorams can realistically deliver.

Program Materials

CarePartner Study Manual: To facilitate caregivers’ online registration for the program, this manual, available in both English and Spanish, provides:

CarePartner Script: This comprehensive document available in both English and Spanish outlines the function of the phone call, e-mail and fax interfaces and includes: 

  1. Questions and feedback heard by the patients during their weekly phone assessment
  1. E-mail reports sent to caregivers after each of the patient’s telephone assessments
  1. Patients’ self-care reports that generate a fax to the patients’ primary care provider. 

CarePartner Web site: The Web site enables the patient-caregiver pair to register via the Internet. During the study, the Web site is the source of caregiver information about the patient’s weekly monitoring call and heart failure education and resources.

System Operations Page: The Operations Page – also available in Spanish – is a portal to view our comprehensive monitoring system.

Functionally, the system allows a case manager to follow a panel of patients based on their automated calling system responses concerning symptoms and self-care. It is capable of cataloging patients’ and caregivers’ interaction with the automated calling system and Web site. 

Back To Top>

Positive Steps: Effective Care Management of Depressed Diabetes Patients

Objectives

QUICCC investigators are developing and evaluating a telephone care management program for patients who are being treated for both diabetes and depression.

The program is designed to promote physical activity and medication adherence using a structured, cognitive behavioral therapy approach. Patients use pedometers to monitor their activity levels and encourage their efforts to reach walking targets developed in conjunction with the nurse care manager. 

Development and Evaluation Plan

With funding from National Institutes of Health, more than 300 patients who are being treated for both diabetes and depression are being recruited from UMHS, the Ann Arbor VA, and Genesys Healthcare System in Flint, Michigan. 

Participants are randomized to one of two groups: 1) brief education about depression, diabetes self-care, and physical activity; or 2) telephone care management including antidepressant medication care management and/or cognitive behavioral therapy. 

Cognitive behavioral therapy includes structured patient and telephone care manager manuals describing session-by-session, a 12-week telephone counseling program. The program includes weekly patient “homework” and background information, and transitions from an initial emphasis on depression to a focus on walking and diabetes (once the depressive symptoms have begun to decrease). 

Outcomes will be measured at 12 months post enrollment and will include measures of patients’ glycemic control, depressive symptoms, activity levels, and self-management behaviors.

Program Materials

Positive Steps Patient and Care Manager Manuals: These parallel manuals guide patients and their telephone care manager through the 12-week Cognitive behavioral therapy program targeting diabetes and depression.

The manuals also include tools for patients to use on their own between telephone care management sessions and during longer-term follow-up.

Back To Top>

The P2P Study: Telephone Peer Support for Diabetes Management

Objectives

Patients with diabetes often have difficulty managing their self-care and accessing clinic-based services; many also lack adequate support to help them meet the demands of their illness. 

Given the growing volume of patients and constraints on health system resources, new models are needed to increase patients’ support without adding significant burden to their health care team. 

QUICCC investigators are developing a model that uses group outpatient visits and patient-to-patient “peer” support to enhance patients’ assistance with self-care and allow them to learn from other patients how best to manage their condition. 

Development and Evaluation Plan

To promote between-visit patient contacts while protecting patients’ privacy, we developed a specialized telephone support service that can be managed by clinic staff with minimal computer expertise. 

Using the system, a patient’s care team can enroll the patient along with another patient peer-partner who is facing the same self-care challenges.

Patients use the system to contact their peer by dialing a toll-free number and using their own telephone number as an ID, avoiding the need for patients to share phone numbers. 

Clinical managers can:

The system automatically contacts both peer partners with an automated reminder if they have not talked within a week, and both partners can leave voice-mail messages for each other or their care manager. 

Patient workbooks provide ideas for what to discuss during the peer calls and give tips for how to be a more effective peer support partner. 

With funding from the VA Health Services Research and Development Program, we are conducting a randomized trial evaluating the impact of these peer support calls plus group visits on diabetes patients’ self-care and health status.  

Program Materials

Peer support Web site: This Web site provides an interface where care managers or clinic staff can manage and monitor diabetes peer support pairs.

The Web site allows staff to:

Nurse case managers have a toll free number they can call to retrieve patient messages left on the system 

Peer Workbook and Care Manager Manual: A written guide for patients to use during their weekly telephone calls with their peer support partner, and a manual to guide care managers through study implementation. 

The workbook includes:

DVD of Motivational Interviewing Techniques: This DVD provides patients with initial education and examples for how to use motivational interviewing techniques to build their peer support communication skills.

Technical Manual (under development): This manual will describe in detail the mechanics of the automated phone system by detailing the capabilities and functions of the system.

Clinic managers and system operators can use the manual to understand the system’s functionality and trouble-shoot problems.

Back To Top>

Buddy Study: Mobilizing Peer Support for Effective Congestive Heart Failure Self-Management

Objectives

QUICCC investigators are developing and evaluating a disease management program for heart failure patients, consisting of a peer-to-peer automated telephone system for patients recently hospitalized for a HF exacerbation. 

The program is designed to:

The goal of the service is to:

Development and Evaluation Plan

During the next two years, approximately 400 patients hospitalized for a heart failure exacerbation will be recruited.

Half of the patients will be randomly assigned to the peer support program and paired with another patient peer partner. Peer partners will use the QUICCC calling system to communicate between group visits, sharing education about HF self-care and emotional support.

The remaining patients will receive brief heart failure education and self-care management information. Outcomes (including the service’s cost-effectiveness) will be measured after three, six and 12 months post-enrollment.

Program Materials

Peer support Web site: This Web site provides an interface allowing care managers or clinic staff to manage and monitor HF peer support pairs.

The Web site allows staff to:

Nurse case managers have a toll free number they can call to retrieve patient messages left on the system 

Peer Workbook and Care Manager Workbook: Each patient in the program receives a workbook that they can use during their weekly telephone calls with their peer support partner.

The workbook includes:

DVD of Motivational Interviewing Techniques: This DVD provides patients with initial education and examples for how to use motivational interviewing techniques to build their peer support communication skills.

Technical Manual (under development): This manual will describe in detail the mechanics of the automated phone system by detailing the capabilities and functions of the system. 

Clinic managers and system operators can use the manual to understand the system’s functionality and trouble-shoot problems.

Back To Top>