Approximately 1.86 million (82.7% of them are ≥ 60 years old) out of 2.6 million care recipients in Germany are living at home. Within this group, the majority (1.25 million) receives support exclusively from informal caregivers without using any professional services [
1]. Caregiver burden or distress is common [
2] and associated with female gender, low education, residence with the care recipient, higher number of hours spent caregiving, depression, social isolation, financial stress, and the lack of choice being a caregiver [
3]. Interventions to support informal caregivers have been evaluated in diverse disease specific contexts like dementia or stroke [
4,
5]. Major components of interventions are psychoeducation, supportive interventions, psychotherapy, respite/day-care, or training of the care recipient [
6]. The interventions are delivered in various ways (e.g. face-to-face or by telephone) and during different stages of the caregiving trajectory. Major endpoints e.g. in dementia caregiver research are depressive symptoms and emotional distress, burden, self-efficacy and coping, and quality of life [
7]. Most of the evaluated heterogeneous interventions for dementia caregivers were effective to some extent [
4], with a robust corpus of intervention studies that demonstrates small but clinically and statistically significant benefits for families [
8]. Despite the evaluation of more than 200 dementia caregiver interventions over the past three decades, only very few programs have been translated to delivery in service contexts [
9]. These rare efforts demonstrate the multiple challenges between required modifications according to staff and organization needs and the preservation of the integrity of the particular intervention [
10].
Over the last years, the German legislature has initiated several new laws within the long-term care act to support care recipients and their caregivers. One regulation (social act / §7a SGB XI) that became effective in 2009 specifies the right for care recipients to get counselling and support by care counsellors (German: “Pflegeberater”). The counsellors usually have qualifications in the field of social work, nursing, or social insurance plus a defined specific training in nursing knowledge, case management, and legislation. The scope of counselling in this context should range from information transfer to case management. Care plans should be made in accordance with family caregivers who (and not the care recipient as insured person) is in most consultations the counsellor’s contact person. Recent laws and counselling practice do not consider caregivers as advice seekers with own needs and interests in a systematic way. While some long term care (LTC) insurances have explicitly addressed caregiver issues in their draft papers or even assessments, the current counselling practice is (to our knowledge) not directly linked to the corpus of evidence-based interventions in this field so far. The first evaluation report from 2012 summarizes that the professional qualification of care counsellors has made good progress, but the ways of implementation are very heterogeneous with regard to insurances, local districts, and states. Burden, mental or physical health outcomes of caregivers, as well as aspects of quality of care were not considered in this national evaluation [
11].
From 2007 to 2010 we conducted a randomized controlled trial (ISRCTN86289718) to evaluate the impact of a mostly telephone-based problem-solving (PS) intervention to distressed family caregivers of German geriatric stroke survivors. The intervention’s effectiveness on depressive symptoms and physical complaints of the caregivers after the main intervention period (month 3) and the maintenance period (month 12) compared to a control group has significantly been proven [
12]. Recent reviews on stroke [
13] and dementia [
14] caregiver research can underline positive effects of problem-solving interventions for this target group. The prevailing conceptualization of problem solving articulated by D’Zurilla and Nezu [
15] describes PS as a general coping strategy with reciprocal relations to stressful life events and emotional stress responses.
The aim of the current study (2013 to 2016) is to train counsellors from nursing care insurances to apply problem-solving as a caregiver specific component and part of an extended care counselling. In a pragmatic trial we want to evaluate the effect of this extension compared to routine counselling on distressed caregivers. In line with the mixed samples of caregivers who receive counselling from LTC insurances, we want to include caregivers of care recipients with all kind of diagnoses (e.g. dementia, stroke, and heart failure). This is in contrast to most of the previous caregiver research that is segmented along different care recipient diagnoses and funding schemes. For the evaluation a cluster randomized design was chosen to prevent contamination of routine counselling of untrained counsellors by improved counselling skills of trained colleagues within the same office. Furthermore, we wanted to prevent that each participating counsellor would have had to switch between two different counselling approaches depending on the group allocation of the caregiver.