Clinical trial NCT04846049: Inter-Disciplinary Outpatient Care Model Providing Comprehensive Geriatric Assessment, Care-Coordination & Co-management
Official title: An Inter-Disciplinary Outpatient Care Model Providing Comprehensive Geriatric Assessment, Care-Coordination and Co-management to High Need High Risk Veterans Meeting HBPC Criteria
Study type: OBSERVATIONAL
Overall status: COMPLETED
Conditions: Veterans
Geriatric Assessment
Care-Coordination
Outpatient Care
Keywords: High Need High Risk
Home Based Primary Care
Lead sponsor: Miami VA Healthcare System
Sponsor class: FED
First posted: 2021-04-15
Enrollment: 206
Sex: ALL
Minimum age (years): 65
Standard ages: OLDER_ADULT
Accepts healthy volunteers: no
Observational model: COHORT
Time perspective: PROSPECTIVE
Sampling method: NON_PROBABILITY_SAMPLE
Study population: High Need High Risk Veterans in Miami Medical Center area

Brief summary: The Department of Veterans Affairs' (VA) Home Based Primary Care (HBPC) program provides comprehensive care to its sickest, frailest Veterans with multiple complex chronic diseases. The HBPC program is a resource intensive non-institutional care program where Veterans, who are not able to receive primary care at the VA, are closely monitored and care is provided using an interdisciplinary team that coordinates the care through multi-professional home visits.

The Geriatric Extended Care recommended that Miami Veteran Affairs Healthcare System (VAHS) HBPC enroll from a list of over 2,000 pre-identified High Need High Risk (HNHR) Miami Veterans for whom HBPC enrollment would have a high likelihood of clinical and economic benefits. HNHR Veterans have the greatest need for care but face the steepest challenges with access. However, despite best of intentions, the Miami HBPC program does not have the capacity to enroll the large numbers of Veterans on this new HNHR list. Therefore, innovative strategies are needed to provide appropriate needed care for this HNHR Veteran population.

Goal: Maintain older Veterans in their homes for as long as possible.

Aims: Design and pilot test an evidence-based, outpatient, Comprehensive geriatric assessment, Care plan based, Care-coordination, Co-management (C4) model, for 100 HBPC eligible HNHR older Veterans who are not enrolled in the HBPC program.

The investigators will develop, implement and evaluate a VA model to provide a comprehensive geriatric assessment of HNHR Veterans, design a structured care plan that includes care coordination to link their needs to appropriate referrals, home and community based services, monitor and coach patients and caregivers, and coordinate their care across VA and non-VA providers and settings.

Objectives:

1. Characterize the needs of the HNHR group of Veterans
2. Evaluate the feasibility and processes of the Geri C4 model
3. Evaluate the impact of the model on patient, healthcare utilization, and other Geriatric Extended Care (GEC) outcomes
4. Determine the facilitators and barriers for implementing the intervention

Detailed description: The intervention will consist of the following components:

1. Comprehensive Geriatric Assessment: A complete geriatric assessment using an interdisciplinary team (geriatrician, psychologist, social worker, dietitian, and nurse). The investigators will increase the number of geriatrician and interdisciplinary team visits to every other month interspersed with their primary care visits.
2. Care Planning: The investigators will review and discuss each participant during the interdisciplinary team meeting. The team will jointly generate a care plan for the implementation of the interventions. The care plan will be shared with the respective primary care provider.
3. Care Coordination: Participant/caregiver will be regularly contacted to confirm that the care plan is being implemented and to allow the participant/caregiver to discuss issues related to the management.
4. Co-management: Primary care provider and project Geriatricians will share responsibility and decision making for participants aiming to prevent and treat geriatric complications.

Eligibility criteria: Inclusion Criteria:

* Hospitalization in prior 12-months
* Received post-acute care in prior 12-months (skilled nursing facility or skilled home health care)
* Two or more chronic conditions
* Two or more activity of daily living impairments or greater or equal to six Frailty Index score
* Less than or equal to 60 minutes of closest VA primary care site.

Exclusion Criteria:

* Enrolled in Home Based Primary Care
* Using hospice Care
* Using palliative care
* In a foster home
* In a nursing home

Primary outcomes:
measure: Changes in FRAIL score
timeFrame: 5 minutes
measure: Change in Montreal Cognitive Assessment (MOCA)
timeFrame: 10 minutes
Secondary outcomes:
measure: Katz Index of Independence in Activities of Daily Living
timeFrame: 10 minutes
measure: Lawton-Brody Instrumental Activities of Daily Living Scale
timeFrame: 10 minutes
measure: Detection of symptoms of depression
timeFrame: 5 minutes
measure: Change in number of clinic visits
timeFrame: 6-months
measure: Change in number of hospital admissions
timeFrame: 6-months
measure: Change in healthcare utilization
timeFrame: 6-months
Other outcomes:
Locations:
city: Miami
country: United States
facility: Miami VA Healthcare System
state: Florida
Study officials:
affiliation: Miami VA Healthcare System
name: Stuti Dang, MD,MPH
role: PRINCIPAL_INVESTIGATOR
References: