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Applying the RE-AIM framework to evaluate a holistic caregiver-centric hospital-to-home programme: a feasibility study on Carer Matters
Open accessAbstract
Background: Prolonged caregiving of an older adult can cause family caregivers to be overwhelmed, potentially affecting the well-being of both the caregivers and their care-recipients. Carer Matters is a holistic hospital-to-home programme, centred on caregivers’ needs as their care-recipients transit from hospital to home. The programme was piloted to support caregivers through caregivers needs assessment, tailored resources, tele-support, training courses, and community support network. This study aimed to examine the feasibility of Carer Matters in a tertiary hospital in Singapore. Methods: This feasibility study was conducted on the pilot implementation from January to December 2021, during the Covid-19 pandemic. It adopted the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The study highlighted quantitative data collected from key process indicators, such as number of caregivers screened, assessed on their needs and provided with assistance. Additionally, qualitative data was collected from in-depth interviews with 51 stakeholders involved in the implementation to examine their perspectives and experiences. These included family caregivers, clinician caregiver support nurses, hospital leaders and community partners. Results: During the pilot, 550 caregivers were enrolled. All caregivers received educational resources when they completed the needs assessment, while 69 of them who reported high burden were given tele-support and 252 attended our caregiver training courses. Despite initial recruitment challenges and obstacles to adoption, stakeholders interviewed found Carer Matters to be effective in providing caregivers with emotional support, knowledge and skills that improved their caregiving abilities, and reduced their sense of isolation and caregiving stress. Among caregivers, the training courses were effective with majority of caregivers agreeing that the courses addressed their needs (99%) and improved their knowledge of the relevant disease conditions (97%). Programme maintenance considered among stakeholders included strategies such as multipronged approach in recruiting caregivers and inviting caregiver advocates to share their experiences. Conclusion: This feasibility study highlights that Carer Matters is a valuable component to the ecosystem of support for family caregivers and their care recipients. Carer Matters extends the current patient-centric care model to a more holistic post-discharge continuity of care for both caregivers and their care-recipients, improving and maintaining their overall well-being to better allow transition from hospital-to home. Trial registration: Feasibility Study of Project Carer Matters for Family Caregivers of Persons with Dementia (NCT number: NCT05205135).
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“In the literature, transitional care support remains patient-focused, which may mean that interventions to improve capability to care may be limited by a failure to support the needs of the carer [112].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [112]
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Metadata
- Authors
- Chan, E. Y., Wu, L. T., Ng, E. J. Y., Glass, G. F., & Tan, R. H. T.
- Affiliations
- National University of Singapore (SG)
- Tan Tock Seng Hospital (SG)
- Corresponding author
- Chan, Ee Yuee
- Venue
- BMC Health Services Research
- Published
- 2022-07-19
- Volume
- 22
- Issue
- 1
- Pages
- 933-933
- ISSN
- 1472-6963 (ISSN-L)
- PMC
- PMC9296119
- OpenAlex
- W4286213876
- Cited by
- 19
- References
- 37
- Citations by year
- 2026: 5 · 2025: 4 · 2024: 6 · 2023: 3 · 2022: 1
- FWCI
- 5.24
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BMC Health Services Research (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- Geriatric Education and Research Institute (GERI1626)
- Topics
- Health Sciences › Nursing › Research and Theory › Nursing care and research
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Medicine › Geriatrics and Gerontology › Geriatric Care and Nursing Homes
- Keywords
- family caregivers, hospital-to-home transition, caregiver burden, dementia, RE-AIM framework, program feasibility, caregiver needs assessment, caregiver education, continuity of care, post-discharge care, caregiver well-being, caregiver isolation
- MeSH terms
- COVID-19, Aftercare, Aged, Feasibility Studies, Hospitals, Humans, Patient Discharge, Social Support, Caregivers, Ecosystem, Pandemics
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