The Impact of Telemedicine to Support Palliative Care Resident in Nursing Home

Study Overview
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Brief Summary
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Investigators hypothesize that telemedicine may be an effective tool to improve palliative care in nursing home, by providing on-site specialized and interprofessional consultation. The objective of this study is to assess the impact of telemedicine in decreasing the rate of hospitalization, compared with usual care, in nursing home resident with palliative care needs.

Detailed Description
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According to current statistics, approximately 12 % of all deaths in France occur in Nursing Home, with the number over 25% in USA. With the ageing of the population, this rate is expected to dramatically increase in the next years, to reach 40% in USA in 2020. Yet, there is some evidence that palliative care is often inadequate in Nursing Home: there is a difficulty to recognize residents who might benefit palliative care and their needs, an underassessment and under-treatment of pain and other end-of-life symptoms, and frequent burdensome treatments and hospitalizations. Several programs including palliative care consult service (with outside consultant), Nursing Home-based palliative care or Nursing Home-hospice partnerships, have succeeded in delivering high-quality palliative care in Nursing Home. But, to our knowledge, no studies examined the benefit of telemedicine for palliative care in nursing home. During a 6 month-inclusion period, residents with palliative care needs will be included in both arms. In the intervention group, Telemedicine consultations involving Nursing Home staff and the palliative and/or geriatric unit from the University Hospital, will be organized systematically at inclusion and during the follow-up if needed. In both groups, hospitalizations and emergency hospitalizations, quality of life of the resident, satisfaction of the nursing home staff and health costs will be recorded during 6 months.

Official Title
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The Impact of Telemedicine to Support Palliative Care Resident in Nursing Home: a Cluster Randomized Control Study.

Conditions
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Palliative Care

Intervention / Treatment
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* Other: usual palliative care
* Other: Telemedicine consultation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Residents with palliative care needs: Diagnosis of advanced or terminal disease: advanced cancer, advanced congestive Hearth Failure, end-stage pulmonary disease, end-stage hepatic disease, end-stage neurologic disease, other end-stage medical diagnosis. ≥ A unplanned acute hospital episodes within the past 6 months Activity of daily life ≤ 1 and/or bed/chair ridden residents for at least 30 days. Weight loss ≥ 10% of body weight in the last 6 months. The  surprise question  approach:  Would I be surprised if this patient died within the next 6-12 months?  Informed and written consent by the patient or the legal representative or the reliable person when appropriate. General Practitioner agreement. Exclusion Criteria: No agreement of study participation of patients or legal representative or the reliable person when appropriate.

Ages Eligible for Study
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Minimum Age: 65 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: Supportive Care
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention group<br>Every patient identified as belonging to a palliative care after the inclusion criteria will receive intervention with a follow-up with Telemedicine consultation | Other: Telemedicine consultation<br>* Establishment of an initial multiprofessional Telemedicine consultation involving a palliative care physician and / or geriatrician, and other physician coordinator of nursing homes, health care team and if possible the patient's treating physician (patient and / or family may participate if they want to). The aim is to define and formalize: Aid to collection and application of advanced directives according to Leonetti Act if the resident is able to do so, or collection of confidence personal choices. Definition of the objectives of care and patient's life and therapeutic adaptation with a focus on pain and uncomfortable symptoms. Access to a mobile team of palliative care or geriatric hospitalization at home, a hospice network, if the patient's situation requires. In case of medical worsening : Possibility of access to consultations and use of emergency by tele-expertise or decision support within a maximum period of 72 hours, with the same objectives that above.<br>|
| Other: Control group<br>Every patient identified as belonging to a palliative care after the inclusion criteria will receive Usual palliative care | Other: usual palliative care<br>* Residents in the control group will receive usual palliative care usually delivered in their nursing homes , according to the habits of the healthcare team and their physician.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Evaluation of tele-expertise effectiveness on hospitalization rates | Evaluation by proportion of subject hospitalized at least one time during follow-up period | through the end of study (24 months) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Evaluation of tele-expertise effectiveness on emergency | Emergency hospitalization rates with proportion of subject hospitalized in emergency at least one time during follow-up period | through the end of study (24 months) | 
| Evaluation of tele-expertise effectiveness on last 15 days of life hospitalization rates | proportion of subject hospitalized in the last 15 days of life at least one time during follow-up period | through the end of study (24 months) | 
| Patient quality of life | Assessed by Palliative Care Outcome Scale (PCOS) | 1 month after inclusion | 
| Patient quality of life | Assessed by Palliative Care Outcome Scale (PCOS) | 3 month after inclusion | 
| Patient quality of life | Assessed by Palliative Care Outcome Scale (PCOS) | 6 month after inclusion | 
| Patient quality of life | Assessed by Palliative Care Outcome Scale (PCOS) | Last patient's 3 days of life | 
| Caregivers satisfaction | Assessed through a satisfaction survey | through the end of study (24 months) | 
| Economical evaluation | Evaluation of taking care costs with french social security scheme data | through the end of study (24 months) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Telemedicine, Nursing Home, Hospitalization