Clinical trial NCT02879357: Palliative Care Population Management Project for Integrated Care Management Program for High-Risk Patients
Official title: Palliative Care Population Management Project for Integrated Care Management Program for High-Risk Patients
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Failure to Thrive
Keywords: Care management
end of life
advanced care planning
palliative care
Lead sponsor: Brigham and Women's Hospital
Sponsor class: OTHER
Collaborators: name: Partners HealthCare
First posted: 2016-08-25
Enrollment: 194
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NON_RANDOMIZED
Intervention model: PARALLEL
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief summary: 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: 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.

Eligibility criteria: Clinician Inclusion Criteria:

1. 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
2. Care for patients enrolled in Brigham and Women's Hospital integrated Care Management Program (iCMP)

Clinician Exclusion Criteria:

1. Resident in Training
2. Non-English Speaking Clinic (e.g. Spanish Clinic)

Patient Inclusion Criteria:

1. Over 18 years of age
2. English Speaker
3. 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
4. Enrolled in Brigham and Women's Hospital integrated Care Management Program

Patient Exclusion Criteria:

1. Patient at Dana-Farber Cancer Institute

Primary outcomes:
measure: Percentage of eligible patients with documented goals of care conversations
timeFrame: from date of determination of eligibility to date of death death during the study period, assessed for up to 18 months
Secondary outcomes:
measure: Median number of days before death of first documented goals of care conversation
timeFrame: from date of determination of eligibility to date of death during the study period, assessed for up to 18 months
measure: Percentage of eligible patients with more comprehensive documentation of goals of care before death
timeFrame: from date of determination of eligibility to date of death during study period, assessed for up to 18 months
Other outcomes:
measure: Completion of eligible conversations
timeFrame: from date of clinician training study start to study end date, assessed for up to 18 months
measure: Length of conversation
timeFrame: from date of clinician training study start to study end date, assessed for up to 18 months
measure: Clinician Confidence
timeFrame: at initial clinician training and end of study (an average of 18 months)
measure: Clinician Attitudes
timeFrame: at clinician training and end of study (an average of 18 months)
measure: Utilization
timeFrame: at end of study (an average of 18 months)
Locations:
city: Boston
country: United States
facility: Brigham and Women's Hospital
state: Massachusetts
Study officials:
affiliation: Dana-Farber Cancer Institute
name: Rachelle E Bernacki, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: Dana-Farber Cancer Institute
name: Susan D Block, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: Brigham and Women's Hospital
name: Rebecca Cunningham, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: Dana-Farber Cancer Institute
name: Joshua R Lakin, MD
role: PRINCIPAL_INVESTIGATOR
References: