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Patients 60 years of age and older are often readmitted into an acute care hospital within 30 days of discharge. These readmissions can be costly for the patient and the facility. According to the Agency for Healthcare Research and Quality, nearly one in five of all hospital patients covered by Medicare are readmitted within 30 days, accounting for $15 billion a year.

Cristina Hendrix, DNS, GNP-BC, FNP, FAAN, associate professor for ɫ�ش�ý (DUSON), founded the ɫ�ش�ý Elder Family/Caregiver Training (DEFT) Center  to address this health care issue.

“Oftentimes elderly patients are discharged from the hospital or a rehabilitation facility to continue their care at home with a caregiver that may lack the knowledge or tools to continue care,” said Hendrix, the Center’s director. “The DEFT Center is designed to assist caregivers in continuing to care for the elderly patient once they transition home. This additional training for the caregiver will hopefully reduce readmissions.”

Hendrix’s research focuses on developing interventions to support the family caregivers of chronically ill patients. “In my years of research, I’ve found that caregivers actually thirst for knowledge and one-on-one training on the skills they will need to care for their loved one at home,” she said. “Therefore, when an opportunity arose for us to obtain funding to develop this program, we jumped on it.”

The DEFT Center was funded by The ɫ�ش�ý Endowment, and its goal is simply to reduce hospital readmissions and preventable emergency department visits with the elderly by focusing on the caregiver. The DEFT core team of experts includes Stephanie Burg, nursing coordinator for the DEFT Center; and Tamara Griffin, MSW. The DEFT leadership team includes Judy Prewitt, DNP, MSN, associate chief nursing officer for ɫ�ش�ý University Health System; Pat Kramer, EdS, ACM, CCM, CSW, NCC, director of Case Management for ɫ�ش�ý University Health System; Eleanor McConnell, PhD, RN, GCNS-BC, associate professor for DUSON; Loretta Matters, MSN, RN, director for the ɫ�ش�ý NICHE at ɫ�ش�ý University Health System and associate director for the Center of Geriatric Nursing Excellence; and Doreen Matters, program director for DEFT.

Burg and Griffin will provide education and skills training to the caregiver during face-to-face classes before their elderly loved one leaves the hospital or skilled nursing facility. The team will then follow the caregiver for 14 days’ post discharge and provide at least two follow-up phone calls and/or video calls with the caregiver.

“Our classes are designed to provide teach-back sessions in group and one-on-one settings,” Burg said. “An additional benefit is that caregivers will be videotaped so they can review themselves once they are at home.”

The DEFT Center launches its pilot program this month, pursuing caregivers of elderly patients being treated in the medical oncology unit, under the leadership of , associate professor of Medicine for ɫ�ش�ý University School of Medicine and a member of the ɫ�ش�ý Cancer Institute. “Our patients are admitted for a wide range of problems that can be related to their disease or their treatment, and they often make significant improvements while in the hospital,” he said. “On the other hand, there is still a challenge in the time period that they leave the hospital.”

Riedel said that upon leaving the hospital, patients sometimes have to deal with new health care needs, such as new medications or medical devices, that can become burdensome for both the patient and the caregiver.

“The DEFT Center will be able to meet these needs for our patients and their caregivers,” Riedel said. “The Center’s education and training will provide an additional layer of support that many of these patients and their families would not otherwise have. This is critical in reducing readmissions with this patient population.”

Prewitt foresees the program as an extension of patient care. “When patients are in the hospital, they are receiving care from our nurses and other health care providers 24 hours a day,” she said. “And while we provide education prior to discharge, it’s still not the same as having that inpatient care they are used to receiving in our facilities. Getting home and realizing they don’t have this can be sheer terror for our patients and their caregivers. This program helps bridge that transition.”

The Center is different than most transitional care models across the country in that it synergizes the strengths and components of a university health system. With the academic component, the DEFT Center is giving DUSON graduate nursing students the opportunity to provide caregiving training. “This approach is a win-win for the Center because it allows us to increase our capacity to assist more caregivers and for our students as it exposes them to difficulties that families often face when caring for a loved one at home,” Hendrix said.

Prewitt added: “Excellent patient care consists of a collaboration between so many health care providers, such as nursing services, physician services, social work, and this program allows us to join these clinical/medical services with academic services and develop a forward-thinking model of care that will greatly benefit our patients and their caregivers.”

To learn more about the DEFT Center, visit nursing.duke.edu/centers-and-institutes/deft