Cirrhosis Medical Home

Study Overview
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Brief Summary
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To address the health care system's lack of care coordination, the Institute of Medicine and Centers for Medicare and Medicaid Services recommend the development of collaborative care models (CCM) in a wide range of clinical settings. CCMs are intended to provide coordinated, personalized care pragmatically using care coordinators. CCMs have successfully improved care in multiple patient populations, ranging from frail older adults to depression. In contrast, for patients with cirrhosis, there is a paucity of data to support the benefit of CCM in this medically complex and vulnerable population. At Indiana University, researchers have over 20 years of experience in developing, testing, and implementing CCMs successfully for patients living with dementia or depression. Building on these successes, we have customized the CCM to best meet the unique and complex biopsychosocial needs of patients with cirrhosis: the Cirrhosis Medical Home.

Detailed Description
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In the Cirrhosis Medical Home, a care coordinator, supported by an interdisciplinary clinical team, will deliver a personalized intervention guided by a set of innovative tools: (i) patient-centered care protocols, (ii) a mobile office, (iii) care coordination support software, and (iv) dynamic feedback measures. The overall goal is to improve quality of life of patients discharged from the hospital with cirrhosis and to reduce acute health care utilization for patients with cirrhosis. Additionally, up to 40 caregivers will be enrolled in the trial.

Official Title
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Cirrhosis Medical Home

Conditions
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Cirrhosis, Liver

Intervention / Treatment
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* Other: Care Coordinator Intervention for Direct Intervention Group
* Other: Care Coordinator Intervention for Standard of Care Group
* Other: Caregiver Intervention


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria for patients: Age ≥18 years Cirrhosis based on: biopsy characteristic clinical, laboratory, and imaging findings Decompensated cirrhosis as denoted by either: active ascites requiring paracentesis during hospitalization or active overt hepatic encephalopathy requiring lactulose during hospitalization Poor quality of life as defined by: SF-36 Physical and/or Mental Component Summary scale <40 (1SD below the mean of healthy subjects) Discharged to home, skilled nursing facility, sub-acute rehabilitation care, or long-term acute care Able to be consented, either in person or through legally authorized representative Access to a telephone Inclusion criteria for caregivers: Age ≥18 years Identified caregiver of patient Able to be consented, either in person or through legally authorized representative Access to a telephone Exclusion Criteria for patients: Solid organ transplant of any organ Life expectancy of less than 6 months Anticipated liver transplant within 6 months History of dementing illnesses and other neurodegenerative diseases such as Alzheimer's disease, Parkinson's disease, or vascular dementia Unable to complete study questionnaire due to hearing loss Legally blind Pregnant or nursing Incarcerated Concurrent enrollment in a related interventional research study Exclusion criteria for caregivers: Impaired cognitive function Unable to complete study questionnaire due to hearing loss Legally blind Incarcerated

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
Interventional Model Description: Block randomization will be utilized to ensure balancing of treatment groups throughout enrollment. 20 participants will be assigned to the direct home interventions group and 20 will be assigned to standard of care. Caregivers (40) belong to a single arm of the study with no randomization. All receive the same study procedures.
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Direct Intervention<br>Initial Evaluation: Prior to discharge, the care coordinator will review the hospital discharge plan, obtain the approval of the patient's physicians to co-manage the patient's care, and schedule a visit with the patient at their place of discharge. Participants in this arm will receive direct interaction with a care coordinator to develop an individualized care plan. Frequent assessments, at least once every two weeks, will occur to continue to follow or to modify the care plan based on the needs of the patient. At the end of 6 months, all patients will be transitioned to receive full care by their primary care and specialty physicians and their participation in this study will be ended. | Other: Care Coordinator Intervention for Direct Intervention Group<br>* The First Visit: The care coordinator will conduct a visit within 72 hours of hospital discharge to assess the patient's physical, cognitive, and psychological status, and will complete a needs assessment for both the patient and family caregiver. These measures will be used to guide the use of care protocols and development of the individualized care plan. The care plan will be developed with an emphasis on coordinating services with the patient's providers. The Second Visit: During the second visit, the coordinator will review the individualized care plan with both the patient and the family caregiver and will make revisions to the plan based on assessment outcomes. The 6-month Interaction Period: Approximately every 2 weeks, the coordinator will meet with the participant to revisit the care plan and to facilitate care. At the end of 6 months, all patients will be transitioned to receive full care by their primary care and specialty physicians.<br>* Other names: Direct Intervention Group;|
| Sham Comparator: Standard of Care<br>Prior to hospital discharge, the care coordinator will identify the primary care and/or hepatology provider of patients in the usual care group and will ensure follow up appointments at the time of hospital discharge. The coordinator will compose and send a letter to the primary care and/or hepatology provider summarizing the patient's diagnosis, hospital course, discharge medications, and the plan of follow-up care. If the patient does not already have a primary care or hepatology provider, the coordinator will work with the patient to identify a new provider. Subjects in this group will receive no further intervention. | Other: Care Coordinator Intervention for Standard of Care Group<br>* For participants randomized to this arm, a consultation with the care team will be arranged prior to hospital discharge. Outcome measures will be obtained by blinded research staff from all enrolled subjects at baseline, 3 months, and 6 months. This is the extent of interventions received for participants in this arm.<br>* Other names: Standard of Care Group;|
| Placebo Comparator: Caregiver<br>The caregivers of people with cirrhosis will be enrolled in the study. They will complete the assessments at baseline, 3 months and 6 months. | Other: Caregiver Intervention<br>* Caregivers of the participants will be assessed for caregiver burden at 3 time points.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Enrollment rate | The proportion of screened patients/caregivers eligible, approached and enrolled will be calculated. This is an internal assessment relating not to participants but to department specific metrics. | 24 months | 
| Number of participants who dropped out | This is the proportion of enrolled participants (patients and caregivers) who drop out of the study before completion. This is an internal assessment relating not to participants but to department specific metrics. | 24 months | 
| Number of participants with complete data | Completeness of the data collection for enrolled subjects and reasons for incomplete data will be recorded. This is an internal assessment relating not to participants but to department specific metrics. | at end of study | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Health Related Quality of Life: Medical Outcome Study Short Form (SF-36) | Assessment from the patient only through data collection from the Medical Outcome Study Short Form (SF-36) instrument. This 36 item questionnaire has a minimum score of 36 with a maximum score of 180; a higher score generally correlates to poorer health. | every 3 months for 6 months, at initial enrollment, 3 month, and 6 month visits | 
| Physical Performance | Assessment from the patient only through data collection from the Short Physical Performance Battery (SPPB) instrument. | every 3 months for 6 months, at initial enrollment, 3 month, and 6 month visits | 
| Depression Symptoms | Assessment from patient only through data collection from the Patient Health Questionnaire-9 (PHQ-9) instrument. This 9 item instrument that assesses depression and has a minimum score of 0 and a maximum score of 27; a lower score generally indicates no or a lesser amount of depression/anxiety than a higher score. | every 3 months for 6 months, at initial enrollment, 3 month, and 6 month visits | 
| Anxiety Symptoms | Assessment from patient only through data collection from the Generalized Anxiety Disorder Scale (GAD-7) instrument. This 7 item instrument that assess anxiety has a minimum score of 0 and a maximum score of 21, with a lower score indicating no or lesser anxiety than a higher score. | every 3 months for 6 months, at initial enrollment, 3 month, and 6 month visits | 
| Cognitive assessment with 3D CAM (Confusion Assessment Method) | Assessment of overall levels of cognitive status, including hepatic encephalopathy | every 3 months for 6 months, at initial enrollment, 3 month, and 6 month visits | 
| Cognitive assessment with PHES (The Psychometric Hepatic Encephalopathy Score) | Assessment of overall levels of cognitive status, including hepatic encephalopathy | every 3 months for 6 months, at initial enrollment, 3 month, and 6 month visits | 
| Caregiver Burden | Assessment from caregivers only through data collection from the Zarit Burden Interview-12 (ZBI-12) instrument; a lower score is generally indicative of a lower amount caregiver fatigue or perception of burden; a higher score generally correlates to a greater level of caregiver fatigue/perceived burden. | every 3 months for 6 months, at initial enrollment, 3 month, and 6 month visits | 
| Acute Health Care Utilization | This is an assessment of patient use of health care resources, including hospitalizations and Emergency room visits. For the patient only, data will be gathered from the patient and medical record relating to the participant's emergency room visits and hospital admissions/inpatient stays during the course of their enrollment in the study. | 6 months | 
| CMH Interactions | During participation in this study, patients randomized to the Cirrhosis Medical Home Arm will meet with study staff, at least every 2 weeks for 6 months to assess overall health of the patient. | every 2 weeks for 6 month enrollment of participant |