Implementation of a Telehealth Palliative Care Model for Persons With Dementia

Study Overview
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Brief Summary
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Grounded in the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) Model, this study will assess the implementation outcomes of the Nurse Practitioner (NP) delivered telehealth Palliative Care Consultation in Post-Acute Care (PCC-PAC) intervention for persons living with dementia (PLWD) and their care-partners newly admitted to nursing homes (NHs) for post-acute care.

Detailed Description
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This single arm embedded pragmatic pilot clinical trial will provide data to assess the implementation outcomes of the Nurse Practitioner (NP) delivered telehealth Palliative Care Consultation in Post-Acute Care (PCC-PAC) intervention among 30 persons living with dementia (PLWD) and their care-partners newly admitted to one nursing homes (NH) for post-acute care.

Official Title
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Implementation of a Telehealth Palliative Care Model for Persons With Dementia

Conditions
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Palliative Care, Dementia

Intervention / Treatment
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* Other: Palliative Care Consultation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Stakeholders: (1) PC provider (2) Social Work (SW) NH champions (3) post-acute care unit nursing staff and providers (including medical directors) (4) NH leadership, information technology staff (5) PLWD and their care partner(s). Person Living with Dementia (PLWD) documented dementia diagnosis admitted for post-acute care age ≥ 60 years if unable to participate in a conversation or lacking capacity to make healthcare decisions as determined by the NH staff/providers, a care partner who can act as a surrogate decision maker in the PCC-PAC. Exclusion Criteria: Stakeholders: -PLWD who receives the intervention PLWD: planned discharge within 48 hours of screening currently receiving hospice care

Ages Eligible for Study
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Minimum Age: 60 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Palliative Care Consultation in Post-Acute Care<br>Subjects will receive usual care plus a telehealth palliative care consultation by specialty providers who will document their findings in the Electronic Health Record (EHR), and communicate their findings and recommendations to the clinical team. | Other: Palliative Care Consultation<br>* The PC provider conducts the structured PCC-PAC via videoconference or telephone with the PLWD and/or their care partner and the social work (SW) champion in the NH. The SW and PC provider will set up a mutually agreed upon consultation day/time with the PLWD and/or care partner, within 5 business days of NH admission and follow up visits will occur no more than 30 days later (if needed).<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Primary Outcome Measure | Adherence to Skilled Nursing Facility (SNF)-PCC recommendations Adherence Protocol. Medical record review Investigators will determine a recommendation adherence score after each participants' encounter. Each recommendation will be assigned 2 points, then will define full (2 points), partial (1 point) and no adherence (0 point) to each recommendation. Investigators will sum the points for each SNF-PCC recommendation and use this as the denominator. Investigators will sum each recommendation with full, partial, no adherence and use this as the numerator. The fraction will be converted to a percentage ranging from 0-100% reflecting the recommendation adherence score. | 30 days post admission | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hospitalizations | Number of hospitalization(s) | 30 days post admission | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Dementia, Palliative Care, Telehealth, Nursing Homes