A Problem Solving Intervention for Hospice Caregivers
Phase: NA
Conditions: Anxiety Generalized, Quality of Life, Depression
Sponsor: George Demiris, PhD

Clinicaltrials.gov ID: NCT03712410 
Title: A Problem Solving Intervention for Hospice Caregivers 
PI: G. Demiris 
Date of Document: December 20, 2022 
 
Study Protocol and Data Analysis 

Design 
The study was designed as a randomized clinical trial with four groups. Hospice caregivers were 
randomly assigned to either to a group receiving standard hospice care with the addition of the 
PISCES intervention delivered face to face (Group 1) or a group receiving standard hospice 
care with the addition of the PISCES intervention delivered in a hybrid format (first session in 
person, remaining sessions via video) (Group 2) or a group receiving standard hospice care 
with the addition of the PISCESplus intervention delivered in a hybrid format (Group 3) or a 
group receiving standard hospice care with the addition of the PISCESplus intervention 
delivered entirely online (Group 4). 
 
Setting and Participants 
We partnered with Penn Homecare and Hospice Services. Penn Homecare and Hospice 
Services is an agency (part of the Penn Medicine system) that is Medicare and Medicaid- 
certified, accredited by the Joint Commission, licensed in the Commonwealth of Pennsylvania. It 
serves patients and families in Philadelphia, Chester, Delaware, Bucks and Montgomery 
counties mostly (total number of counties serves is 20) and is experiencing a growth over the 
years (20% increase in admissions over the past 5 years). The hospice component of the 
agency had a total number of 2,970 home admissions, an average daily census of 380 and an 
average length of service (LOS) of 68 days in 2016 
Inclusion criteria for caregivers were the following: 
• 
enrolled as a family/informal caregiver of a hospice patient 
• 
18 years or older 
• 
with access to a standard phone line or Internet and computer access at home 
• 
without functional hearing loss or with a hearing aid that allows the participant to conduct 
telephone conversations as assessed by the research staff (by questioning and 
observing the caregiver) 
• 
no or only mild cognitive impairment—mental status will be assessed using the Short 
Portable Mental Status Questionnaire;i individuals with a score of less than seven (i.e., 
more than three errors) will be excluded, similar to other studies involving this 
instrument. 
• 
speak and read English, with at least a 6th-grade education 
 
Enrollment 
The hospice admissions staff presented the research opportunity to caregivers upon admission, 
asking them if they agree to be contacted by the research staff to find out more about the study. 
The admissions staff then forwarded contact information for caregivers willing to learn more 
about the study to the research team if they fulfilled the eligibility criteria. The interventionist 
called and scheduled the initial visit. The interventionist visited the caregiver, discussed the 
project, obtained informed consent from the caregiver, and documented demographic data. The 
interventionist opened a numbered sealed envelope, prepared by the team in advance, which 
assigned caregivers to one of the three groups. This approach ensured that consent is obtained 
prior to group assignment and caregivers consent to participate in the study, regardless of group 
assignment. Randomization was stratified by site. Furthermore, we followed a block 
randomization approach to ensure that treatment groups are not imbalanced with respect to 
time of the year as season (e.g., holidays) may have an effect on some of the psychometric 
measures. Upon consent, caregivers were asked to review and prioritize common caregiver 
concerns using a checklist, as the intervention will focus on the top three concerns or problems. 
Following this visit, a research assistant called the caregiver to conduct the baseline 
assessment (including anxiety, quality of life, caregiver reaction and problem solving inventory) 
over the phone. The research assistant was blinded to the caregiver’s group assignment to 

eliminate any potential bias. While the pre- and post assessments were conducted by the 
research assistant over the phone, the consent visit, actual intervention visits/ video-calls and 
exit interviews were delivered by an interventionist. 
 
Group 1: PISCES delivered face to face 
Before departing, the interventionist tentatively scheduled the upcoming three face-to-face visits 
for caregivers, and leave a manual on problem-solving designed for the lay audience based on 
“Solving Life’s Problems” by Nezu and D’Zurilla who developed the PST theoretical frameworkii 
with a special emphasis on hospice and hospice specific examples. The three intervention visits 
were scheduled with a suggested timeline between days 5 and 18 of the hospice admission. 
This timeline was calculated based on average length of stay for our participating hospice 
agency and also on national level as well as based on the PST recommendations86 and 
previous work on cognitive behavioral interventions in hospice.iii However, this was only a 
guideline, and the actual timing and scheduling was tailored to the individual caregiver needs 
and challenges (the visits were scheduled and confirmed based on the caregiver’s feedback 
and preferences and with the recognition that unexpected and stressful events can lead to 
frequent rescheduling). Each intervention visit lasted approximately 45 minutes. 
The agenda for the first face to face visit for caregivers (suggested timeline 5-7 days after 
hospice admission) includes an explanation of the purpose of the visit/call, and confirmation of 
the three specific problems that the caregiver had selected from the concern list during the 
consent visit. Caregivers’ problem-solving inventory scores and sub-scales indicate their 
problem-solving style (positive problem orientation, negative problem orientation, rational 
problem-solving, impulsivity/carelessness and avoidance6) and this allows the interventionist to 
customize the delivery of the intervention. During the first session, the interventionist works on 
steps one and two of the ADAPT model of the PST, namely “Attitude” and “Defining the Problem 
and Setting Realistic Goals.” For the first step the focus is on realistic optimism, i.e., acceptance 
that problems are a normal part of life. This step focuses on promoting visualizing successful 
problem solving, healthy thinking rules, positive self-talk and using emotions adaptively. The 
problems identified by the caregiver will be used as examples for exercises and to brainstorm 
about applying different approaches. The second step of defining the problem focuses on 
enabling caregivers to seek available facts, describe facts in a clear language, separate facts 
from assumptions, set realistic goals and identify obstacles to overcome. 
During the second visit (suggested timeline 11-13 days after hospice admission) the 
interventionist covers steps three and four of the ADAPT model. Step three encourages 
caregivers in being creative and generating alternative solutions. This step involves 
brainstorming possible solutions to the identified problem, encouraging caregivers to brainstorm 
many alternatives, defer judgment on these alternatives until a later stage of the intervention 
and think of a wide range of possible strategies (general) and tactics (more specific). Step four 
focuses on predicting the consequences and developing a solution plan. This step involves 
evaluating alternatives and choosing the one that is most likely to effectively solve the identified 
problem. Making effective decisions involves screening out obviously ineffective solutions, 
predicting possible consequences, evaluating solution outcomes, and identifying effective 
solutions/developing a solution plan. 
The third visit (suggested timeline 16-18 days after hospice admission) focuses on step five, 
namely trying out the solution plan and determining if it works. The general goal is to 
systematically evaluate the solution that caregivers implemented as a result of the previous 
steps to determine if it was effective in solving (or improving) the identified problem. 
 
Group 2: PISCES delivered in a hybrid format 
In this group, participants received the PISCES intervention in three sessions; however, the first 
session was delivered face to face and the other two via video. The three intervention sessions 

were scheduled with a suggested timeline between days 5 and 18 of the hospice admission as 
in Group 1. 
The first session took place in person (suggested timeline 5-7 days after hospice admission) 
and included an explanation of the purpose of the visit/call, and confirmation of the three 
specific problems that the caregiver had selected from the concern list. During the first session, 
the interventionist worked on steps one and two of the ADAPT model of the PST, namely 
“Attitude” and “Defining the Problem and Setting Realistic Goals.” After the first session where 
the in person encounter allowed for the establishment of rapport between the interventionist and 
the caregiver, the second session (suggested timeline 11-13 days after hospice admission) and 
the third session (suggested timeline 16-18 days after hospice admissions) were conducted via 
live videoconferencing. 
 
Group 3: PISCESplus delivered in a hybrid format 
PISCESplus is meant to be an enhanced version of the PISCES intervention including the 
original problem solving therapy modules as designed for PISCES with the addition of positive 
reappraisal elements added to the curriculum. The agenda for the first face to face visit for 
caregivers (suggested timeline 5-7 days after hospice admission) includes an explanation of the 
purpose of the visit/call, and confirmation of the three specific problems that the caregiver had 
selected. During the first session, the interventionist works on steps one and two of the ADAPT 
model of the PST, namely “Attitude” and “Defining the Problem and Setting Realistic Goals.” 
Additionally, at the end of the first session, the interventionist will ask the caregiver to take the 
time until the next scheduled session to think about and identify some positive aspects of 
caregiving, whether these are tasks or responsibilities they enjoy, or other elements of the 
caregiving experience that they perceive as positive or beneficial. 
During the second session (suggested timeline 11-13 days after hospice admission) which took 
place via video the interventionist covers steps three and four of the ADAPT model. At the end 
of the session the interventionist asked the caregiver to go over the benefits or positive aspects 
of caregiving that they had identified and asked them to comment as to why they perceive these 
as positive or beneficial and whether there are ways to maximize the perceived benefits. The 
interventionists asked the caregiver to take the time until the next scheduled session to record 
how the appreciation of these positive elements helps them through stressful situations or when 
they have negative thoughts. 
The third session (suggested timeline 16-18 days after hospice admission) which also takes 
place via video focuses on step five, namely trying out the solution plan and determining if it 
works. The interventionist concluded the session by briefly discussing the caregiver’s perceived 
positive aspects of caregiving and reiterating the importance of recognizing and celebrating 
these aspects during the caregiving trajectory. 
Group 4: PISCESplus delivered online 
In this group the entire PISCESplus is delivered online. The first session is conducted via video 
and not in person (as is the case in Group 3). The agenda for the first video visit for caregivers 
(suggested timeline 5-7 days after hospice admission) includes an explanation of the purpose of 
the visit/call, and confirmation of the three specific problems that the caregiver had selected. 
During the first session, the interventionist works on steps one and two of the ADAPT model of 
the PST, namely “Attitude” and “Defining the Problem and Setting Realistic Goals.” Additionally, 
at the end of the first session, the interventionist will ask the caregiver to take the time until the 
next scheduled session to think about and identify some positive aspects of caregiving, whether 
these are tasks or responsibilities they enjoy, or other elements of the caregiving experience 
that they perceive as positive or beneficial. 
During the second session (suggested timeline 11-13 days after hospice admission) which took 
place via video the interventionist covers steps three and four of the ADAPT model. At the end 
of the session the interventionist asked the caregiver to go over the benefits or positive aspects 

of caregiving that they had identified and asked them to comment as to why they perceive these 
as positive or beneficial and whether there are ways to maximize the perceived benefits. The 
interventionists asked the caregiver to take the time until the next scheduled session to record 
how the appreciation of these positive elements helps them through stressful situations or when 
they have negative thoughts. 
The third session (suggested timeline 16-18 days after hospice admission) which also takes 
place via video focuses on step five, namely trying out the solution plan and determining if it 
works. The interventionist concluded the session by briefly discussing the caregiver’s perceived 
positive aspects of caregiving and reiterating the importance of recognizing and celebrating 
these aspects during the caregiving trajectory. 
 
After all three intervention sessions were completed, a research assistant (blinded to the group 
assignment) called caregivers in all four groups for a post-intervention assessment of anxiety, 
depression, quality of life and problem solving inventory. This segregation of responsibilities and 
the blinding of the research assistant to the group assignment aimed to minimize any potential 
bias. Caregivers received a phone exit interview a few days after the last intervention visit and 
post intervention assessment phone call. 
 
Treatment Fidelity 
To ensure treatment fidelity to the planned interventions, we used the training and treatment 
fidelity manual refined during previous work. The guide details the training of research staff, the 
nature of each of the three intervention sessions, and the protocol for administering each of the 
evaluative instruments. All face to face visits and all video-calls were audio-taped by the 
research staff and a randomly chosen sample of 10% of all sessions were studied. Thus, the 
integrity of the intervention protocol was systematically assessed via reviews of audio 
recordings of these sessions. Tapes were rated by the principal investigator (PI) for overall 
adherence to the protocol and inclusion of all required elements, as well as to confirm that no 
contamination took place (e.g., a case where the interventionist provided specific advice for a 
problem without allowing the caregiver to review and select an option). The research team was 
required to make adjustments if interventions were violating the intervention protocol. The 
intervention manual included our intervention monitoring tools (IMTs) that were refined based on 
recommendations by Radziewicz et aliv to help assure fidelity in individualized intervention 
studies. 
 
Measures 
Measures for Specific Aims 1 and 2: 
Generalized anxiety disorder (GAD-7): The GAD-7 is a brief, valid and efficient tool for 
screening for anxiety and assessing its severity in clinical practice and research. The GAD-7 
has been tested and demonstrated high levels of reliability and validity.v The total score is 
calculated by assigning scores of 0-3 for each of the seven items. Scores of 5, 10, and 15 are 
taken as the cut off points for mild, moderate, and severe anxiety, respectively. 
Problem-Solving Inventory (PSI): The PSI is a 25 item Likert-type inventory that serves as a 
measure of problem-solving appraisal, or an individual’s perceptions of their problem-solving 
behavior and attitudes.vi The total score is used as an overall index of problem-solving ability. 
Reliability and validity of this instrument have been documented extensively (Cronbach’s Alpha 
reported at .85). 
Caregiver Quality of Life Index – Revised (CQLI-R): The CQLI-R, a measure of caregivers’ 
quality of life (QOL), includes four dimensions: emotional, social, financial, and physical.vii This 
four-item instrument was designed specifically for hospice caregivers, and its reliability and 
validity have been established. The instrument has been used successfully with elderly hospice 
caregivers.viii Our research team has revised the CQLI instrument for use in oral interviews 

using 0 and 10 for each of the four anchors in place of the visual analog scale.ix Cronbach’s 
alpha for the revised instrument (CQLI-R) was 0.769, and test-retest reliability was supported 
(rs = 0.912, p<0.001). 
Nine-item Depression scale of the Patient Health Questionnaire (PHQ-9): The PHQ-9 is a brief 
tool for assisting clinicians and researchers in assessing and monitoring levels of depression.x 
The PHQ-9 assesses symptoms and functional impairment due to depression and derives a 
severity score. It is based directly on the diagnostic criteria for major depressive disorder in the 
Diagnostic and Statistical Manual Fifth Edition (DSM-V). It is widely used in practice and has 
been extensively tested (kappa = 0.65; overall accuracy, 85%; sensitivity, 75%; specificity, 
90%). While all other measures described above were also used in our original clinical trial, the 
PHQ-9 is a new measure we are planning to utilize; we decided to include a depression 
measure as it has been found to be impacted by the positive reappraisal modules in other 
studies. 
Demographic data: Standard demographic data were collected on patients and caregivers, 
including age, gender, nativity, education level, marital status, occupation, patient’s diagnosis, 
relationship to patient, location of residence (residing with patient or not), estimate of average 
time spent on caregiving activities per week, impact on employment (whether caregiver had to 
decrease work hours or give up employment) and perceived income adequacy (having a 
comfortable income, having just enough to get by, not having enough to get by). Furthermore, if 
the patient dies during the subject’s participation, that will be recorded along with the date of 
death (to allow for calculation of timing of death in the context of subject’s days in the study). 
Table 1 demonstrates the timeline for the collection of these measures. 
 
Table 1: Timeline for data collection 
1 
Baseline 
2 
Pre- 
Interventio 
n 
Assessme 
nt 
3 
4 
5 
6 
Post-intervention 
Assessment 
7 
Exit 
interview 
Group 1 
PISCES 
delivered 
face to 
face 
Delivered 
by: 
Demo- 
graphic 
data 
F2F 
I 
Measures 
(PHQ-9, 
CQLI-R, 
PSI, GAD- 
7 ) 
Telephone 
RA 
(blinded to 
group 
assignment 
) 
PST 
Session 
1 
F2F 
I 
PST 
Sessio 
n 2 
F2F 
I 
PST 
Session 
3 
F2F 
I 
Measures 
(PHQ-9, CQLI-R, 
PSI, GAD-7 ) 
Telephone 
RA (blinded to 
group 
assignment) 
Telephon 
e 
RA 
Group 2 
PISCES 
delivered in 
a hybrid 
format 
Demo- 
graphic 
data 
F2F 
Measures 
(PHQ-9, 
CQLI-R, 
PSI, GAD- 
7 ) 
Telephone 
PST 
Session 
1 
F2F 
PST 
Sessio 
n 2 
Video 
PST 
Session 
3 
Video 
Measures 
(PHQ-9, CQLI-R, 
PSI, GAD-7 ) 
Telephone 
Exit 
interview 
Telephon 
e 

Delivered 
by: 
I 
RA 
(blinded to 
group 
assignment 
) 
I 
I 
I 
RA (blinded to 
group 
assignment) 
RA 
Group 3 
PISCESplu 
s delivered 
in a hybrid 
format 
Delivered 
by: 
Demo- 
graphic 
data 
F2F 
I 
Measures 
(PHQ-9, 
CQLI-R, 
PSI, GAD- 
7 ) 
Telephone 
RA 
(blinded to 
group 
assignment 
) 
PST+ 
positive 
reapprai 
sal 
Session 
1 
F2F 
I 
PST+ 
positiv 
e 
reappr 
aisal 
Sessio 
n 2 
Video 
I 
PST+ 
positive 
reapprai 
sal 
Session 
3 
Video 
I 
Measures 
(Measures 
(PHQ-9, CQLI-R, 
PSI, GAD-7 ) 
Telephone 
RA (blinded to 
group 
assignment) 
Exit 
interview 
Remove 
video 
Telephon 
e 
RA 
Group 4 
PISCESplu 
s delivered 
online 
Demo- 
graphic 
data 
Measures 
(PHQ-9, 
CQLI-R, 
PSI, GAD- 
7 ) 
PST+ 
positive 
reapprai 
sal 
Session 
1 
PST+ 
positiv 
e 
reappr 
aisal 
Sessio 
n 2 
PST+ 
positive 
reapprai 
sal 
Session 
3 
Measures 
(Measures 
(PHQ-9, CQLI-R, 
PSI, GAD-7 ) 
Exit 
interview 
Remove 
video 
Video 
Telephone 
Video 
Video 
Video 
Telephone 
Telephon 
e 
Delivered 
by: 
I 
RA 
(blinded to 
group 
assignment 
) 
I 
I 
I 
RA (blinded to 
group 
assignment) 
RA 
I=Interventionist; RA=Research Assistant; F2F=Face-to-Face 
 
Measures for Specific Aim 3 
We conducted exit interviews with caregivers in all three groups. Caregivers in Group 1 were 
asked to provide general feedback about the PISCES intervention. Exit interviews with 
caregivers in Groups 2, and 3 also assessed caregivers’ perceptions of the hybrid delivery 
platform (face to face and video sessions); caregivers in Groups 3 and 4 were further asked to 
provide feedback on the positive reappraisal aspects of PISCESplus. Interviews were carried 
out by the research coordinator and audio-taped based on an interview protocol aiming to 
examine caregivers’ perceptions and satisfaction. Interview questions pertained to satisfaction 
with this form of interaction, barriers and facilitators to the use of video, and confidence in using 
this form of interaction, lasted 20 to 30 minutes. The interviews were digitally recorded and 
transcribed. The QSR Nvivo11 software was used to manage and interpret the data. This 
software facilitates the organization of emerging ideas, to search and explore in context, and to 
seek patterns. 
 
Measures for Specific Aim 4: 

We conducted a cost analysis and we utilized the demographic data collected on enrollment in 
the study to allow for comparisons between the groups. These include hospice admission date 
and diagnosis, patient and informal caregiver age and sex, race, informal caregiver employment 
status, education and income range, relationship of informal caregiver to patient, and residence 
of the informal caregiver. We also equipment costs (including equipment price and 
depreciation), and training costs based on time to train research staff in the use of 
videoconferencing. The participating hospice agency also furnished the research team with the 
following client-level data to estimate resource use and costs: 
• direct care time for scheduled visits by type of professional 
• travel distance and time spent traveling for scheduled visits by type of professional 
• direct care time for after-hour calls and visits by type of professional 
• travel distance and time spent traveling for after-hour visits by type of professional 
• time and travel associated with the installation and maintenance of videophones and 
addressing potential technical problems 
• average salary paid by type of professional 
• number and cost of hospital or emergency room visits for patients. 
 
Other Measures 
We assessed the quality of the video calls using a previously developed instrument for 
assessing the technical quality of a “virtual visit” in home care,xi a video-based interaction 
between health care providers and patients or caregivers. This instrument is a form that will be 
filled out by the research staff after each video-session with a caregiver in Groups 2 and 3. The 
form includes identification of the caregiver, date, starting and ending time of the video-call. The 
main section of the form contains five items regarding the technical quality of the video-call. The 
first two items refer to the observations made by the research staff in regard the frequency of 
difficulties with audio and image by the research staff. The next two items address problems 
with video and sound at the caregiver’s end, as reported to the research staff during the video- 
call. The last item addresses possible disconnection(s) and their frequency of occurrence. This 
section allows for the definition of a score for the overall technical quality of each video-call. This 
instrument has been tested for reliability and validity and used to rate the technical quality of 
video-calls in home care settings.xii 
 
Data Analysis Plan 
Data Analysis for Specific Aims 1 and 2 
The primary analyses focused on examining differences between treatment groups in terms of 
caregiver outcomes during the time of intervention. Changes in caregivers’ scores from baseline 
to post-treatment will be analyzed using analysis of covariance, with baseline score, site, and 
whether the caregiver’s patient has died, as covariates. Separate models were run for each 
outcome (caregiver quality of life, anxiety, depression, and problem-solving ability). For Specific 
Aim 1 (SA1) to assess the equivalence between PISCES F2F and PISCES in hybrid format, a 
confidence interval approach was used on the ANCOVA model, with a two-sided 5% leveI of 
significance. If the CI of the difference between the two groups falls within the pre-specified 
range of equivalence, the two interventions will be considered equivalent.xiii xiv The range of 
equivalence is defined between – Δ and + Δ. The clinically informed Δs for the primary 
outcomes are: CQLI-R = 1.0; GAD-7 = 1.75; PHQ-9 = 2.0; PSI = 2.5, respectively. The analyses 
of equivalence will be on a per-protocol basis and will be supplemented by secondary sensitivity 
intent-to-treat analyses.55 
The analyses for Specific Aim 2 (SA2) focus on pair-wise comparisons between PISCESplus 
and the other treatment groups. A significance level of α=0.025 for each comparison was used 
to account for the multiple (2) comparisons and assure an overall significance level of no more 
than 0.05 for each outcome. These analyses of superiority was on an intent-to-treat basis, using 

multiple imputation to address missing data. ANCOVA and chi-square tests were used to 
determine whether attrition had an impact on sample composition. Specifically, analyses were 
computed on baseline demographic characteristics, as well as baseline outcome measures, to 
determine whether participants who completed all phases of data collection were initially 
different when compared with persons who did not complete the intervention. Data were 
analyzed using the Stata statistical package. 
 
Data Analysis for Specific Aim 3 
Interview sessions were audio-recorded and transcribed. Data were analyzed using a qualitative 
thematic coding approach. Data codes were inductively generated. Data analysis was 
performed by two members of the research team and validity of interpretations was checked by 
a third member. Transcript data were coded by line and sentence for descriptive (first-level) and 
theme (pattern) codes.65 A list of major thematic elements was extracted by thorough study and 
coding of the interview transcripts. The analysis was organized into an expanding list of themes, 
arising from content, concepts, and descriptive categories (the process will be supported by the 
use of QSR NVivo11, an index-based qualitative analysis software package). The thematic 
elements was used to develop coding keywords. Each response was coded along a number of 
salient dimensions, such as topic, thematic content, and general sentiment using the previously 
abstracted keywords. Data were grouped and reviewed for trends and patterns or ideas that 
give insight into caregivers’ overall satisfaction with the intervention, their perception of the 
hybrid delivery platform (for Groups 2 and 3) and of the positive reappraisal modules (for Group 
3). Perceived benefits and challenges associated with both the focus and content of the 
intervention and its components as well as the mode of delivery were examined. 
 
Data Analysis for Specific Aim 4 
Our cost analysis compared the three intervention groups with respect to total costs. Using the 
resource use and cost information, and the cost of client-specific hospitalizations and 
emergency department visits as described earlier, we estimated the total cost of care for each 
client. These data were used as the dependent variable in four pair wise regression analyses 
comparing the four groups with respect to total costs incurred over the study timeframe. 
Analysis of variance methods was employed. We also examined resource use, and compared 
this between groups. Specifically, we compared the number of after-hours calls and, and the 
number of hospitalizations and emergency department visits. As these outcome variables are 
each an event-count, each cannot be truly normal in distribution. Traditional regression methods 
assume a normally distributed outcome with constant variance. In contrast, count data are 
discrete and usually involve many observations with identical values and often highly right- 
skewed due to a few individuals with extreme event counts. We used both Poisson regression 
and the Zero-Inflated Poisson model for a comparison of the number of after-hour visits and 
calls. We also controlled for demographic covariates in these models. Direct and indirect costs 
for the hospice program were computed as the sum of implementation and operating costs. 
Intervention implementation costs included equipment costs (based on equipment price and 
depreciation), and staff training costs. Operating costs were measured by staff costs (wages 
and time) for delivery of the intervention (based on average wages and average time research 
staff took to do the intervention), and costs of home visits (frequency and duration) by all 
hospice staff as documented in the record review. Caregiver costs were based on overall 
informal care time (using income data gather upon admission), intervention time, any time lost 
from work, and out-of-pocket and travel expenditures related to caregiving as reported by the 
caregiver during the exit interview. 

Table 1: Participant characteristics 
 
Variable 
Traditional Pisces 
Online Pisces 
Group 1 
(n = 154) 
Group 2 
(n = 152 ) 
Group 3 
(n = 154) 
Online 
(n = 63) 
P-value 
Caregiver Age [Mean (Std.)] 
56.8 (12.7) 
58.8 (12.8) 
57.4 (12.2) 
56.1 
(17.2) 
0.5664 
Caregiver GAD 7 Score [Mean (Std.)] 
6.69 (5.4) 
5.74 (4.9) 
6.32 (4.9) 
5.85 (5.2) 
0.4236 
Caregiver PHQ-9 Score [Mean (Std.)] 
7.54 (5.7) 
6.6 (5.4) 
6.99 (5.3) 
6.78 
(5.36) 
0.5267 
Caregiver QOL Score [Mean (Std.)] 
27.7 (8.0) 
28.5 (8.4) 
29.32 (7.2) 
28.31(7.7) 
0.4168 
Caregiver Status 
Bereaved 
Active 
43 (28.7%) 
47 (31.5%) 
46 (30.9%) 
4 (6.4%) 
0.0010 
107 (71.3%) 102 (68.5%) 103 (69.1%) 59 (93.6%) 
Caregiver Diagnosis 
Cancer 
Dementia 
Other 
11 (21.6%) 
6 (13.6%) 
10 (22.2%) 
5 (21.7%) 
<0.0001 
2 (3.9%) 
3 (6.8%) 
2 (4.4%) 
13 (56.5%) 
38 (74.5%) 
35 (79.6%) 
33 (73.4%) 
5 (21.7%) 
Caregiver Dementia 
No 
Yes 
Don’t Know 
14 (25.5%) 
8 (17.0%) 
9 (18.4%) 
1 (3.7%) 
< 0.0001 
6 (10.9%) 
4 (8.5%) 
5 (10.2%) 
21 (77.8%) 
35 (63.6%) 
35 (74.5%) 
35 (71.4%) 
5 (18.5%) 
Caregiver Gender 
Male 
Female 
Decline to Answer 
23 (15.1%) 
34 (23.1%) 
20 (13.3%) 12 (19.1%) 
0.2271 
129 (84.9%) 113 (76.9%) 130 (86.0%) 51 (80.9%) 
0 (0%) 
0 (0%) 
1 (0.7%) 
0 (0%) 
Caregiver Ethnicity 
Hispanic 
Non-Hispanic 
Decline to Answer 
7 (4.6%) 
8 (5.4%) 
11 (7.3%) 
9 (14.3%) 
0.1708 
138 (90.8%) 136 (92.6%) 134 (88.7%) 51 (80.9%) 
7 (4.6%) 
3 (2.0%) 
6 (4.0%) 
3 (4.8%) 
Caregiver Race 
Black/African American 
White/Caucasian 
Other 
64 (41.6%) 
56 (36.8%) 
53 (34.4%) 23 (36.5%) 
0.3958 
72 (46.7%) 
82 (54.0%) 
79 (51.3%) 28 (44.4%) 
18 (11.7%) 
14 (9.2%) 
22 (14.3%) 12 (19.1%) 
Caregiver Marital Status 
Single/Never Married/Partnered 
Married/Partnered 
Widowed 
Separated/Divorced 
Decline to Answer 
37 (25.5%) 
38 (26.8%) 
25 (18.5%) 20 (32.3%) 
67 (46.2%) 
69 (48.6%) 
76 (56.3%) 33 (53.2%) 
0.2715 
23 (15.9%) 
16 (11.3%) 
20 (14.8%) 
2 (3.2%) 
18 (12.4%) 
18 (12.7%) 
14 (10.4%) 
7 (11.3%) 
0 (0%) 
1 (0.7%) 
0 (0%) 
0 (0%) 
Caregiver Education 
Less than High School 
High School/GED 
Some College/Associate Degree 
Bachelor’s Degree 
Graduate/Professional Degree 
2 (1.4%) 
1 (0.7%) 
2 (1.5%) 
0 (0%) 
0.4536 
24 (16.5%) 
27 (19.0%) 
25 (18.5%) 
6 (9.7%) 
38 (26.2%) 
42 (29.6%) 
43 (31.9%) 17 (27.4%) 
40 (27.6%) 
27 (19.0%) 
37 (27.4%) 17 (27.4%) 
41 (28.3%) 
45 (31.7%) 
28 (20.7%) 22 (35.5%) 
Caregiver Relation 

Spouse/Partner 41 (28.3%) 
42 (29.6%) 
41 (30.4%) 15 (24.2%) 
0.8435 
Adult Child 
70 (48.3%) 
69 (48.6%) 
74 (54.8%) 38 (61.3%) 
Parent 
7 (4.8%) 
7 (4.9%) 
5 (3.7%) 
1 (1.6%) 
Sibling 
6 (4.1%) 
4 (2.8%) 
3 (2.2%) 
1 (1.6%) 
Other 
20 (13.8%) 
20 (14.1%) 
12 (8.9%) 
7 (11.3%) 
Decline to Answer 
1 (0.7%) 
0 (0%) 
0 (0%) 
0 (0%) 
Care Receiver Gender 
Male 
Female 
69 (47.9%) 
75 (52.1%) 
59 (41.6%) 
83 (58.4%) 
69 (51.9%) 
64 (48.1%) 
15 (24.2%) 
47 (75.8%) 
0.0023 
Care Receiver Ethnicity 
Hispanic 
Non-Hispanic 
Decline to Answer 
6 (4.2%) 
8 (5.6%) 
11 (8.3%) 
5 (8.1%) 
0.6190 
136 (94.4%) 133 (93.7%) 120 (90.2%) 55 (88.7%) 
2 (1.4%) 
1 (0.7%) 
2 (1.5%) 
2 (3.2%) 
Care Receiver Race 
Black/African American 
White/Caucasian 
Other 
63 (40.9%) 
55 (36.2%) 
50 (32.5%) 25 (39.7%) 
0.7531 
75 (48.7%) 
84 (55.3%) 
87 (56.5%) 33 (52.4%) 
16 (10.4%) 
13 (8.5%) 
17 (11.0%) 
5 (7.9%) 
Care Receiver Marital Status 
Single/Never Married/Partnered 
Married/Partnered 
Widowed 
Separated/Divorced 
19 (13.2%) 
18 (12.7%) 
12 (9.0%) 
10 (16.1%) 
0.9220 
57 (39.6%) 
59 (41.6%) 
58 (43.3%) 
24 (38.7%) 
47 (32.6%) 
45 (31.7%) 
49 (36.6%) 19 (30.7%) 
21 (14.6%) 
20 (14.1%) 
15 (11.2%) 
9 (14.5%) 
Care Receiver Residence 
Private Home Residence/Adult Group 
Home 
Assisted Living Facility/Nursing 
Home/Skilled Nursing Facity 
Other 
123 (84.8%) 115 (81.0%) 117 (87.3%) 54 (87.1%) 
0.0488 
18 (12.4%) 
4 (2.8%) 
22 (15.5%) 
5 (3.5%) 
13 (9.7%) 
4 (3.0%) 
2 (3.2%) 
6 (9.7%) 
Caregiver Distance from Receiver 
With you 
Less than 1 hour away 
More than 1 hour away 
Decline to Answer 
90 (62.0%) 
72 (51.0%) 
81 (60.4%) 37 (59.7%) 
0.1859 
49 (33.8%) 
61 (43.3%) 
42 (31.3%) 19 (30.6%) 
4 (2.8%) 
8 (5.7%) 
10 (7.5%) 
6 (9.7%) 
2 (1.4%) 
0 (0%) 
1 (0.8%) 
0 (0%) 
Caregiver Time Caring 
Less than 1 year 
1-3 years 
3 years or more 
Decline to Answer 
42 (29.0%) 
46 (32.6%) 
40 (29.9%) 
13 (21.0%) 
0.1432 
32 (22.0%) 
31 (22.0%) 
28 (20.9%) 26 (41.9%) 
69 (47.6%) 
62 (44.0%) 
65 (48.5%) 22 (35.5%) 
2 (1.4%) 
2 (1.4%) 
1 (0.7%) 
1 (1.6%) 
Caregiver Time Spent Caring per week 
Less than 5 hours 
5-10 hours 
11-20 hours 
More than 20 hours 
Decline to Answer 
6 (4.1%) 
10 (7.1%) 
7 (5.2%) 
4 (6.5%) 
0.7655 
16 (11.0%) 
20 (14.2%) 
12 (9.0%) 
11 (17.7%) 
22 (15.2%) 
13 (9.2%) 
20 (14.9%) 
9 (14.5%) 
100 (69.0%) 
96 (68.1%) 
93 (69.4%) 37 (59.7%) 
1 (0.7%) 
2 (1.4%) 
2 (1.5%) 
1 (1.6%) 
Caregiver Added Expense 

Yes 
No 
Decline to Answer 
112 (77.2%) 
32 (22.1%) 
1 (0.7%) 
104 (73.8%) 
36 (25.5%) 
1 (0.7%) 
100 (74.6%) 
33 (24.6%) 
1 (0.8%) 
43 (69.3%) 
19 (30.7%) 
0 (0%) 
0.9065 
Caregiver Work Status 
Yes 
No 
Decline to Answer 
61 (42.1%) 
83 (57.2%) 
1 (0.7%) 
66 (46.8%) 
75 (53.2%) 
0 (0%) 
61 (45.5%) 
73 (54.5%) 
0 
27 (43.5%) 
35 (56.5%) 
0 (0%) 
0.8126 
Caregiver Work Support 
Cut back on hours or quit work entirely 
Taken an unpaid leave or any leave 
under Family Medical Leave Act 
Left one job for a different one 
Used your own sick leave or vacation 
time 
Taken a job or worked additional hours 
to earn more money 
None of these apply 
Decline to Answer 
Selected More than 1 option 
18 (21.9%) 
15 (19.7%) 
16 (20.0%) 
4 (11.4%) 
0.1053 
5 (6.1%) 
4 (5.3%) 
6 (7.5%) 
1 (2.9%) 
1 (1.2%) 
3 (3.9%) 
1 (1.3%) 
2 (5.7%) 
20 (24.4%) 
13 (17.1%) 
15 (18.7%) 
9 (25.7%) 
1 (1.2%) 
0 (0%) 
2 (2.5%) 
2 (5.7%) 
8 (9.8%) 
4 (5.3%) 
6 (7.5%) 
9 (25.7%) 
4 (4.9%) 
8 (10.5%) 
5 (6.2%) 
0 (0%) 
25 (30.5%) 
29 (38.2%) 
29 (36.2%) 
8 (22.9%) 
 
 
 
 
Table 2. Comparison of 4 groups 
 
Variable 
Group 1 
Mean (Std) 
Group 2 
Mean (Std) 
Group 3 
Mean (Std) 
Group 4 
Mean (Std) 
p-value 
Difference (FollowUp-Baseline) GAD-7 
-2.54 (4.25) 
-1.49 (4.06) 
-2.27 (4.56) 
-1.52 (5.12) 
0.1860 
Difference (FollowUp-Baseline) PHQ9 
-2.69 (4.29) 
-1.56 (4.19) 
-1.87 (4.59) 
-2.02 (4.14) 
0.2752 
Difference (FollowUp-Baseline) CLQI 
1.14 (6.42) 
0.77 (4.82) 
0.27 (7.17) 
1.15 (5.80) 
0.6233 
p-value calculated using Kruskal Wallis Test 
Table 3. Comparison of Traditional PISCES vs. Online PISCES 
 
Variable 
Traditional PISCES 
Mean (Std) 
Online PISCES 
Mean (Std) 
p-value 
Difference (FollowUp-Baseline) GAD-7 
-2.04 (4.18) 
-2.03 (4.74) 
0.5638 
Difference (FollowUp-Baseline) PHQ9 
-2.15 (4.27) 
-1.91 (4.44) 
0.9848 
Difference (FollowUp-Baseline) CLQI 
0.96 (5.70) 
0.54 (6.76) 
0.9169 
p-value calculated using Wilcoxon Two Sample Test 
 
 
Table 4. Within-Group Comparison Baseline vs. Follow-up 
 
Variable 
Traditional PISCES 
Mean (Std) 
p-value 
Online PISCES 
Mean (Std) 
p-value 
GAD-7 
-2.04 (4.18) 
<0.0001 
-2.03 (4.74) 
<0.0001 
PHQ9 
-2.15 (4.27) 
<0.0001 
-1.91 (4.44) 
<0.0001 

CLQI 
0.96 (5.70) 
0.0155 
0.54 (6.76) 
0.0504 
p-value calculated using Wilcoxon Signed Rank Test 
 
 
 
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