Helping Seniors Plan for Posthospital Discharge Needs Before a Hospitalization Occurs: Results from the Randomized Control Trial of PlanYourLifespan.org

RESULTS

Among 470 participants screened for eligibility, 385 were randomized (Figure). All were included in intention-to-treat analysis. Of the 191 participants allocated to the AC group, 1 participant partially received the PYL intervention. The mean age of participants was 71.9 (standard deviation = 5.6), and 79.5% were female; 62.9% identified as white and 37.1% as non-white (Table 1). Baseline characteristics were similar in both of the groups.

Table 2 presents follow-up summary statistics by arm for the UHS score. At both the 1- and 3-month time points, the mean UHS score in the active intervention arm increased (by 0.56 ± 1.55 points at 1 month and 0.60 ± 1.63 at 3 months), while mean UHS score decreased in the AC arm at both time points (−0.09 ± 1.43 at 1 month and −0.07 ± 1.37 at 3 months).

Table 3 illustrates linear mixed model results both failing to adjust and adjusting for potentially influential baseline covariates. In both instances, the interaction term (arm-by-time) was highly significant (P < 0.0001) in predicting UHS score, suggesting that, when compared to the AC arm, the intervention arm exhibited a large mean slope in UHS score over time. That is, understanding home services score tended to increase at a faster rate for those in the active arm. Higher levels of income (P = 0.0191), literacy (P = 0.0036), and education (P = 0.0042) were associated with increased UHS scores; however, male sex (P = 0.0023) and history of high blood pressure (P = 0.0409) or kidney disease (P = 0.0278) were negatively associated with UHS scores.

CONCLUSION/DISCUSSION

The results of our study show that among seniors, PYL improved their understanding of home-based services and the services that may be required following a hospitalization. Educating seniors about what to expect regarding the transition home from a hospital before a hospitalization even occurs may enable seniors and their families to plan ahead instead of reacting to a hospitalization. PYL, a national, publicly available tool with links to local resources may potentially help in advancing transitional discharge care to prior to a hospitalization.

To our knowledge, this is one of the first websites and trials devoted to planning for seniors’ health trajectory as they age into their 70s, 80s, 90s, and 100s. Clinicians regularly discuss code status and powers of attorney during their end-of-life discussions with patients. We encourage clinicians to ask patients, “What about the 10 to 20 years before you die? Have you considered what you will do if you get sick or need help at home?” While not replacing a social worker, the ability of PYL to connect seniors to local resources makes it somewhat of a “virtual social worker.” With many physician practices unable to afford social workers, PYL provides a free-of-charge means of connecting seniors to area resources.

A major strength of this project was our strong community partnerships. PYL was developed with significant input from our patient partners/stakeholders, which included seniors, senior community group leaders, Area Agencies on Aging, Villages, nurses, caregiver agency leaders, and clinicians. This patient and stakeholder engagement enabled us to create a website that was fully senior-centric, focusing specifically on what was important to seniors. Patient partners/stakeholders were tasked with recruiting participants for the trial, using multiple tactics in their communities to connect potential participants to researchers. Recruiting directly through our community partners helped us include people who would not normally participate in research studies. An additional study strength was that recruitment occurred at multiple sites, including rural and urban locales.

As with all studies, limitations exist. While using a validated outcome measure would have been ideal for measuring knowledge, none existed that assessed whether a person understood their future needs or could plan to make use of available resources. Consequently, the UHS outcome measure was not validated prior to starting this trial and it remains unclear what changes in UHS score observed mean or translate to in a real-world setting.

The study participants were in general white, educated, and in reasonably good health. This may be a limitation of this study given that it could impact the generalizability of the study results, as we are unable to know for certain if these same results would be observed with participants who have lower educational levels and are in poor health. Power considerations in this study did not account for comparison of outcomes within specific subgroups so we were unable to assess outcomes in groups such as those with limited health literacy, low social support, or low self-efficacy. The trial was also limited by our inability to collect information on whether or not the knowledge gains observed in the study led to any measureable outcomes. Due to the relatively short follow-up time, we were unable to ascertain whether any study participants were hospitalized during the study follow-up period and if so, if exposure to PYL had any impact on patient anxiety, length of hospital stay, and/or caregiver burden. We were also unable to assess patients’ ability to utilize and carry out their posthospitalization discharge plans if they had one in place. Future studies with longer follow-up are needed to determine these important, measurable outcomes.

Potential implications of planning for a senior’s lifespan are expansive. If hospitalized seniors knew their preferred SNF for subacute rehabilitation on the first day of their hospitalization, hospital lengths of stay could potentially be reduced. If families knew which caregiver agencies, Area Agency on Aging, or Village their senior wished to use, obtaining services would perhaps be easier to accomplish.