Trial of Mount Sinai Palliative Care at Home

Study Overview
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Brief Summary
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The proposed project is a randomized controlled trial of a new home-based palliative care program for adults with serious illness and their caregivers within the Mount Sinai Health System. Potential subjects will be identified from Mount Sinai records or referred by a Mount Sinai healthcare provider. Patients will only be approached after authorization by their Mount Sinai physician. Participants who consent to enrollment will be randomized to receive the intervention (home-based palliative care program) or usual care (with their nominated Mount Sinai physician). Patients will be enrolled in the study for a minimum of 6 months. After 6 months, patients can remain in the program if there is ongoing clinical need; data collection beyond 6 months will be done on all patients through chart abstraction/ administrative claims only. Effectiveness of the intervention will be determined through assessment of patient and caregiver reported outcomes and abstraction of data from medical records and administrative claims. Impact on the following parameters will be measured: (i) Patient symptoms, quality of life, satisfaction with care, documentation of advanced directives, receipt of care consistent with preferences (ii) Caregiver burden, satisfaction with care, and depression (iii) Healthcare utilization and costs of care.

Detailed Description
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The objective of this randomized controlled trial is to study the impact of a new home based palliative care program on patients' symptoms, quality of life, satisfaction with care, completion of advance care planning documentation and receipt of care consistent with preferences. In addition, the study will examine the impact of this model of care on patient healthcare utilization, including hospitalization, emergency department utilization, and hospice use prior to death. The trial will also include patients' caregivers, in order to examine the impact of the intervention on caregiver burden and prevalence of depression. Patients randomized to the intervention will be scheduled for an intake visit. This visit will be undertaken by the team's registered nurse and/or social worker, together with a community health worker, and other team members (advanced practice nurse, MD), depending on patients' needs. Following this visit, and in conjunction with the nurse practitioner and/or MD, a care plan will be developed to address areas of clinical need highlighted during the intake visit. Patients in the intervention arm will receive ongoing monitoring and input (telephone-based and in-person) from members of the clinical team, dependent on their identified needs. Patients' cases will be discussed at the weekly IDT meeting, as appropriate to the level of clinical need. Patients and caregivers will be provided with access to a 24 hour telephone line, staffed by a Mount Sinai based physician, which acts as an advice line out of hours. These physicians will be able to provide advice to patients and caregivers.

Official Title
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Clinical Trial of Home Palliative Care for Seriously Ill Adults

Conditions
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Organ Failure

Intervention / Treatment
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* Behavioral: Home Palliative Care


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Presence of a serious medical illness - according to pre-specified diagnostic code-based criteria Subject has a Mount Sinai physician who authorizes their participation in the study and receipt of the program Subject is resident in Manhattan outside of a long term care facility and is not receiving hospice 5. Subject has evidence of capacity to benefit from enrollment in palliative care program Subject is conversant in English or Spanish Subject has capacity to consent Exclusion Criteria: Subject has no usual physician within Mount Sinai Subject's usual physician doesn't provide authorization to patient participation Subject resident outside of Manhattan or in long term care facility or receiving hospice Subject is not conversant in English or Spanish Subject cannot provide informed consent to participation Dementia (where the subject does not have the capacity to consent)

Ages Eligible for Study
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Minimum Age: 21 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: Patients and caregivers are randomized to receive care from the home-based palliative care team or will receive usual care from their primary physician
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Home Palliative Care<br>Randomized to Intervention Arm | Behavioral: Home Palliative Care<br>* Patients/caregivers will be cared for by an interdisciplinary team that includes a social worker, nurse, community health worker, nurse practitioner, and physician.<br>|
| No Intervention: Control Arm<br>Usual Care - Patients will be cared for by the physician who treats their primary illness(es). | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Integrated Palliative Outcomes Scale | Patient symptoms determined by the Integrated Palliative Outcomes Scale, a validated structured questionnaire administered to patient-subjects via telephone interview or in person by the trained research coordinator. The Integrated Palliative Outcomes Scale is scored on a likert scale from 0-4, with higher score indicating worse symptoms. | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| McGill quality of life-revised | McGill quality of life-revised is a 14 item instrument administered to patient-subjects via telephone interview or in person by the trained research coordinator. Each item score on likert scale from 0-10, full scale from 0-140 with higher score indicating better quality of life. | 6 months | 
| Family Satisfaction with End-of-Life Care (FAMCARE-10) | FAMCARE-10 to assess patient satisfaction by using a validated 10-item structured questionnaire administered to patient-subjects via telephone interview or in person by the trained research coordinator. FamCare each item score on likert scale 0-3, total scale from 0-30, with higher score indicating higher satisfaction | 6 months | 
| Number of Completion of Advance Directives | Study team will examine the patient's chart for completion of advanced directives. | 6 months | 
| Number of Preference Consistent Care | Study team will examine if the care patients receive is concordant with the care they wanted to receive. simple chart review of whether care received matches stated preferences (yes/no). | 6 months | 
| Zarit Burden Inventory | Zarit Burden Inventory to determine caregiver burden by using a validated structured 22-item questionnaire administered to caregiver-subjects via telephone interview or in person by the trained research coordinator. Each item is on a 5-point score range from 0 (never) to 4 (always). Full scale from 0 to 88, with higher score indicating more burden. | 6 months | 
| FAMCARE-10 | FAMCARE-10 to assess caregiver satisfaction by using a validated 10-item structured questionnaire administered to patient-subjects via telephone interview or in person by the trained research coordinator. FamCare each item score on likert scale 0-3, total scale from 0-30, with higher score indicating higher satisfaction. | 6 months | 
| The Patient Health Questionnaire (PHQ-9) | PHQ-9 to assess Caregiver Depression by using a validated structured 9 item questionnaire administered to caregiver-subjects via telephone interview or in person by the trained research coordinator. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as 0 (not at all) to 3 (nearly every day). Full scale from 0-27, with higher score indicating worse depression. | 6 months | 
| Number of inpatient admissions | Number of inpatient admissions to measure healthcare utilization | 6 months | 
| Number of emergency department visits | Number of emergency department visits to measure healthcare utilization | 6 months | 
| Number of outpatient appointments | Number of outpatient appointments to measure healthcare utilization | 6 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Palliative Care, Home-Based Care