Inter-Disciplinary Outpatient Care Model Providing Comprehensive Geriatric Assessment, Care-Coordination & Co-management

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

Get a concise snapshot of the trial, including recruitment status, study phase, enrollment targets, and key timeline milestones.

Recruitment Status

COMPLETED

Total Enrollment

206 participants

Study Classification

OBSERVATIONAL

Study Start Date

2018-04-16

Study Completion Date

2022-03-31

Brief Summary

Review the sponsor-provided synopsis that highlights what the study is about and why it is being conducted.

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

Related Clinical Trials

Explore similar clinical trials based on study characteristics and research focus.

Group Medical Visits in Heart Failure

NCT02481921

Heart Failure

COMPLETED NA

Evaluating Telehealth Home Care for Elderly Veterans With Congestive Heart Failure

NCT00057200

Heart Failure Telemedicine

COMPLETED NA

Evaluation and Support Care Process Within the Care Pathway of Heart Failure Patients

NCT04878263

Heart Failure Acute

COMPLETED NA

Prevention of Early Readmission in Elderly Congestive Heart Failure Patients

NCT00000475

Cardiovascular Diseases Heart Diseases Heart Failure, Congestive +1 more

COMPLETED PHASE2

Enhancing Caregiver Support for Heart Failure Patients: the CarePartner Study

NCT00555360

Heart Failure, Congestive

COMPLETED NA

Detailed Description

Dive into the extended narrative that explains the scientific background, objectives, and procedures in greater depth.

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.

Conditions

See the medical conditions and disease areas that this research is targeting or investigating.

Veterans Geriatric Assessment Care-Coordination Outpatient Care

Study Design

Understand how the trial is structured, including allocation methods, masking strategies, primary purpose, and other design elements.

Observational Model Type

COHORT

Study Time Perspective

PROSPECTIVE

Study Groups

Review each arm or cohort in the study, along with the interventions and objectives associated with them.

Comprehensive Care

Veterans with complex medical conditions that may need more help. This intervention will provide extra care coordination after a complete assessment of their health.

Research team will assess veteran's memory, physical function, strength, balance, and from there, find the areas they need the most help with and coordinate services at home. This is in addition to their regular primary care provider.

Comprehensive Care

Intervention Type OTHER

1. Comprehensive Geriatric Assessment (3 visits with a geriatrician alternating with 3 primary provider visits over 6 months)
2. Care Planning with Interdisciplinary Team
3. Care coordination
4. Co-management with Primary care
5. Social work needs assessment
6. Patient-centered telehealth using phone, home telehealth, patient portal, Video
7. Transportation provided for all visits
8. Referral to Geriatric primary care clinic and mental health per Veteran need
9. Goals of Care and Veteran preferences conversation
10. Educate primary care providers about HNHR population, home and community based services, collaboration

Standard Care

Veterans receiving standard of care

Standard Care

Intervention Type OTHER

No intervention or treatment will be provided.

Interventions

Learn about the drugs, procedures, or behavioral strategies being tested and how they are applied within this trial.

Comprehensive Care

1. Comprehensive Geriatric Assessment (3 visits with a geriatrician alternating with 3 primary provider visits over 6 months)
2. Care Planning with Interdisciplinary Team
3. Care coordination
4. Co-management with Primary care
5. Social work needs assessment
6. Patient-centered telehealth using phone, home telehealth, patient portal, Video
7. Transportation provided for all visits
8. Referral to Geriatric primary care clinic and mental health per Veteran need
9. Goals of Care and Veteran preferences conversation
10. Educate primary care providers about HNHR population, home and community based services, collaboration

Intervention Type OTHER

Standard Care

No intervention or treatment will be provided.

Intervention Type OTHER

Eligibility Criteria

Check the participation requirements, including inclusion and exclusion rules, age limits, and whether healthy volunteers are accepted.

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.