Improving Palliative Care Through Teamwork

Study Overview
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Brief Summary
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One in three Americans dies in a nursing home (NH) or in a hospital, shortly following transfer from a long-term care facility. The proportion of deaths occurring in NHs is projected to increase to 40% by 2020. Excellence in palliative and end-of-life (EOL) care must become a priority for these long-term care institutions. However, findings from NHs point to high incidence of pain and poor management of other symptoms and excessive reliance on hospitalizations, indicating inadequate EOL care quality. Expert opinion and research have suggested that poor EOL quality in NHs may be due to lack of palliative care training among staff and absence of EOL care protocols or guidelines, but research demonstrating that attention to these factors improves outcomes is absent. While dedicated care teams have been shown to improve outcomes for NH residents in need of specialized care, the impact of palliative care teams in improving resident outcomes has remained largely unstudied and untested. This will be the first randomized controlled trial to evaluate the impact of palliative care teams (PCTeam) on resident and staff outcomes, and care processes, in NHs. Our objective is to demonstrate, using a randomized controlled trial design and a difference in difference analytic approach, that nursing home-based palliative care practice guidelines implemented through PCTeams will improve quality of care processes and outcomes for residents at the end of life. We will adapt existing palliative care guidelines for EOL care, endorsed by the National Quality Forum (NQF), to the NH environment, deploy the adapted practice guidelines through a PCTeam model, and evaluate the effectiveness of this intervention on resident EOL outcomes and staff care processes and outcomes. The specific aims (SA) will address the following questions: SA 1: Is PCTeam intervention effective in improving NH residents' EOL outcomes? SA 2: Is PCTeam intervention effective in improving NH staff EOL care processes and outcomes? In the context of these specific aims we will test the following hypotheses: H1: Residents in NHs in the intervention arm, compared to the control, will achieve better EOL risk-adjusted outcomes and care processes with regard to: Pain Dyspnea Depression In-hospital deaths Hospitalizations Advance directives H2: Direct care staff in NHs in the intervention arm, compared to the control, will achieve better EOL processes and outcomes measured by: Assessment of EOL symptoms Delivery of EOL care Communication/coordination among providers Communication with residents/families Teamwork effectiveness Staff satisfaction H3: Family caregivers of decedent residents in the intervention NHs, compared to the control, will report receiving more patient and family centered care as measured by higher levels of satisfaction with: Shared decision making between providers, the patient and the family Care that is respectful of the patient wishes and dignity Attention to the emotional and spiritual needs of the family. 31 NHs in upstate New York have been recruited for the study (letters of support). Stakeholders include residents, family members, staff, policy makers, and others. The intervention will deploy theTeamSTEPPS, a team development model created by the Department of Defense and the Agency for Healthcare Research and Quality.

Official Title
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Improving Palliative and End-of-Life Care in Nursing Homes

Conditions
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Palliative Care

Intervention / Treatment
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* Behavioral: Palliative Care Team (PCTeam)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: long-stay nursing home residents (>90 days) Exclusion Criteria: rehabilitative, post-acute residents (<90 days)

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Palliative Care Team (PCTeam)<br>Palliative care teams will be established and will round with residents in the intervention homes. | Behavioral: Palliative Care Team (PCTeam)<br>* Palliative care teams will be established and will round with residents in the intervention nursing homes.<br>|
| No Intervention: Standard care<br>Usual care will be provided to residents in the control homes. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hospital Site of Death: Number of Decedents Cared for in an Enrolled and Assigned NH Facility, Who Were Transferred to a Hospital and Died in the Hospital During the Study Period | This outcome measure, Hospital Site of Death, assesses whether death occured in a nursing home or in a hospital following transfer from the nursing home, among nursing home residents who were cared for in an enrolled facility. | 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hospitalizations | Number of hospitalizations in the last 90 days of life among decedents being cared for in the enrolled nursing homes | The last 90 days of life |