Palliative Care Population Management Project for Integrated Care Management Program for High-Risk Patients

Study Overview
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Brief Summary
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The hypothesis of the Serious Illness Care Program (SICP) is that adherence to the Serious Illness Conversation Guide (SICG) portion, the SIGC, will enhance patient understanding and allow control over their own decisions, relieve burdens of decision-making on family members, and help patients achieve a state of peace as they approach the end of life.

Detailed Description
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The aim of the Serious Illness Care Program (SICP) is to provide clinicians with an evidence-based structure for eliciting and documenting vital information about preferences for patient driven care of their serious illness. It is designed to help open the door for patients, families, and clinicians to talk and reflect on end-of-life issues in an ongoing way. The hypothesis of the Serious Illness Care Program is that adherence to the conversation guide portion, the SIGC, will enhance patient understanding and allow control over their own decisions, relieve burdens of decision-making on family members, and help patients achieve a state of peace as they approach the end of life. For this protocol specifically, the investigators are testing a pilot intervention of a quality improvement project; the investigators plan to train clinicians and assess the feasibility and impact of the Serious Illness Care Program, which includes patient identification, clinician training, triggering of clinicians to conduct the SICG conversation, and documentation, in the iCMP at the Brigham and Women's Hospital.

Official Title
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Palliative Care Population Management Project for Integrated Care Management Program for High-Risk Patients

Conditions
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Failure to Thrive

Intervention / Treatment
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* Behavioral: Training


Participation Criteria
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Eligibility Criteria
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Clinician Inclusion Criteria: Brigham and Women's Hospital or Newton Wellesley Primary Care Clinician at one of the following practices: The Phyllis Jen Center for Primary Care, Faulkner Community Physicians, Brigham and Women's Physician Group, Brigham & Women's Primary Care Associates of Brookline, Brigham Circle Medical Associates, Faulkner Care for patients enrolled in Brigham and Women's Hospital integrated Care Management Program (iCMP) Clinician Exclusion Criteria: Resident in Training Non-English Speaking Clinic (e.g. Spanish Clinic) Patient Inclusion Criteria: Over 18 years of age English Speaker Patient at Brigham and Women's Hospital or Newton Wellesley Primary Care Clinician at one of the following practices: The Phyllis Jen Center for Primary Care, Faulkner Community Physicians, Brigham and Women's Physician Group, Brigham & Women's Primary Care Associates of Brookline, Brigham Circle Medical Associates, Faulkner Enrolled in Brigham and Women's Hospital integrated Care Management Program Patient Exclusion Criteria: 1. Patient at Dana-Farber Cancer Institute

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: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Trained Clinicians<br>Training in Serious Illness Communication Guide | Behavioral: Training<br>* Clinician training System for patient selection System of triggering and tracking conversations Training on how to use the Serious Illness Care Guide, a guide for patients about initiating conversations with family members about end-of-life goals and values Longitudinal Medical Record (LMR) documentation module to serve as a Single source of truth about advance care preferences in the LMR.<br>|
| No Intervention: Untrained Clinicians<br>No training in Serious Illness Communication Guide | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Percentage of eligible patients with documented goals of care conversations | For patients whose death falls during the study period, the percentage of goals of care conversations completed and documented in the electronic medical record by clinicians in the intervention group and the control group. A completed conversation is defined by key elements being documented regarding goals of care in the patient's medical record. | from date of determination of eligibility to date of death death during the study period, assessed for up to 18 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Median number of days before death of first documented goals of care conversation | For all patients whose death falls during the study period, the median number of days from the date of the first documented goals of care conversation to date of death in both the intervention and the control group. | from date of determination of eligibility to date of death during the study period, assessed for up to 18 months | 
| Percentage of eligible patients with more comprehensive documentation of goals of care before death | For all patients whose death falls during the study period, the percentage of patients with more comprehensive goals of care documentation before death in both the intervention group and the control group. More comprehensive is defined as documentation of a goals of care conversation that addresses more than code status only and will be evaluated for completeness in containing more key elements of a Serious Illness Care Guide conversation. | from date of determination of eligibility to date of death during study period, assessed for up to 18 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Care management, end of life, advanced care planning, palliative care