Palliative Care Population Management Project for Integrated Care Management Program for High-Risk Patients

NCT ID: NCT02879357

Last Updated: 2019-10-11

Basic Information

• Recruitment Status: COMPLETED
• Clinical Phase: NA
• Total Enrollment: 194 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2014-03-31
• Study Completion Date: 2017-12-31

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.

Conditions

Failure to Thrive

Study Design

• Allocation Method: NON_RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: HEALTH_SERVICES_RESEARCH
• Blinding Strategy: NONE

Study Groups

Trained Clinicians

Training in Serious Illness Communication Guide

Group Type: EXPERIMENTAL

Training

Intervention Type: BEHAVIORAL

1. Clinician training

2. System for patient selection

3. System of "triggering" and tracking conversations

4. Training on how to use the Serious Illness Care Guide, a guide for patients about initiating conversations with family members about end-of-life goals and values

5. Longitudinal Medical Record (LMR) documentation module to serve as a "Single source of truth" about advance care preferences in the LMR.

Untrained Clinicians

No training in Serious Illness Communication Guide

Group Type: NO_INTERVENTION

No interventions assigned to this group

Interventions

Training

1. Clinician training

2. System for patient selection

3. System of "triggering" and tracking conversations

4. Training on how to use the Serious Illness Care Guide, a guide for patients about initiating conversations with family members about end-of-life goals and values

5. Longitudinal Medical Record (LMR) documentation module to serve as a "Single source of truth" about advance care preferences in the LMR.

Intervention Type: BEHAVIORAL

Eligibility Criteria

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)

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

Exclusion Criteria

1. Resident in Training

2. Non-English Speaking Clinic (e.g. Spanish Clinic)

1. Patient at Dana-Farber Cancer Institute

• Minimum Eligible Age: 18 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

Partners HealthCare

OTHER

Sponsor Role: collaborator

Brigham and Women's Hospital

OTHER

Sponsor Role: lead

Responsible Party

Bernacki, Rachelle E.,M.D.

Rachelle Bernacki, M.D., M.S.

Responsibility Role: PRINCIPAL_INVESTIGATOR

Principal Investigators

Rachelle E Bernacki, MD

Role: PRINCIPAL_INVESTIGATOR

Dana-Farber Cancer Institute

Susan D Block, MD

Role: PRINCIPAL_INVESTIGATOR

Dana-Farber Cancer Institute

Rebecca Cunningham, MD

Role: PRINCIPAL_INVESTIGATOR

Brigham and Women's Hospital

Joshua R Lakin, MD

Role: PRINCIPAL_INVESTIGATOR

Dana-Farber Cancer Institute

Locations

Brigham and Women's Hospital

Boston, Massachusetts, United States

Countries

United States

Other Identifiers

2014P000211

Identifier Type: -

Identifier Source: org_study_id