Caregiver Connection

Establishing a system to support family caregivers of seniors and adults with disabilities

Full Project Name:Building A Healthy Family Caregiver System Through Early Identification & Right-Time SupportPrimary Community Organization:ERAs Senior Network, Inc.Primary Academic Partner:Leslie Ruffalo, PhD, Family and Community MedicineAward Amount:$474,360

Award Date

January2019

Project Duration:48 months

Project Description Narrative:

Within the ineffective, fragmented, network of organizations encountered by chronically ill seniors and their caregivers, it is not standard or common for caregivers to receive timely, relevant information to assist them along with consistent support. Caregivers of chronically ill seniors require a coordinated, consistent, collaborative system of health care, government and community. Project partners seek to establish a system that provides early identification in the senior's continuum of care and gives timely, relevant, appropriate support to family caregivers.

Community partners: SortSol Group, GE Healthcare, Froedtert Health, Capri Senior Communities, Capri Senior Communities, ADRC of Waukesha County, Caregiver representatives

Outcomes & Lessons Learned:

Conducted rigorous system mapping at each of the three key agencies: Eras Senior Network, Aging and Disability Resource Center (ADRC) of Waukesha County, and Froedtert Health
Analyzed the processes and interactions within the current system with a focus on mechanics of the system and the interactions as experienced by the caregiving unit, effective/ineffective processes, uniformity of service delivery, and identification of personnel involved in the system
Conducted interviews with patients, family caregivers, and healthcare professionals, identifying a need for better/more awareness about community care options, more support for caregivers during a patient’s hospital stay and after discharge, and improved communication
Convened the hospital discharge/readmission research group to understand how informal, unpaid family caregivers are identified, assessed for their willingness and capabilities, and connected to patients during the discharge process
Disseminated project efforts through eight presentations through both academic and community-facing presentations