Study Results
The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.
Basic Information
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RECRUITING
NA
300 participants
INTERVENTIONAL
2023-06-08
2027-03-01
Brief Summary
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Detailed Description
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Patients randomized to the intervention will be scheduled for an intake visit. This visit will be undertaken by the team's registered nurse and/or social worker, together with a community health worker, and other team members (advanced practice nurse, MD), depending on patients' needs. Visits will combine a combination of video-teleconferencing technology and in person visits. Following this visit, and in conjunction with the nurse practitioner and/or MD, a care plan will be developed to address areas of clinical need highlighted during the intake visit.
Patients in the intervention arm will receive ongoing monitoring and input (telephone-based, video-based, and in-person) from members of the clinical team, dependent on their identified needs. Patients' cases will be discussed at the weekly IDT meeting, as appropriate to the level of clinical need. Patients and caregivers will be provided with access to a 24 hour telephone line, staffed by a Mount Sinai based physician, which acts as an advice line out of hours. These physicians will be able to provide advice to patients and caregivers.
Conditions
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Study Design
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RANDOMIZED
PARALLEL
HEALTH_SERVICES_RESEARCH
SINGLE
Study Groups
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Palliative care at home
Randomized to intervention arm
Home Palliative Care
Patients/caregivers will be cared for by an interdisciplinary team that includes a social worker, nurse, community health worker, nurse practitioner, and physician.
Augmented control
Randomized to augmented control (visits to the caregiver from a CHW without training in dementia or palliative care)
Home Palliative Care
Patients/caregivers will be cared for by an interdisciplinary team that includes a social worker, nurse, community health worker, nurse practitioner, and physician.
Interventions
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Home Palliative Care
Patients/caregivers will be cared for by an interdisciplinary team that includes a social worker, nurse, community health worker, nurse practitioner, and physician.
Eligibility Criteria
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Inclusion Criteria
* impairment in at least one activity of daily living (ADL -which is inherent in this level of GDS)
* at least one hospitalization or ED visit within the last 12 months
* a physician who is primarily responsible for their dementia-related care whose clinical outpatient site is associated with one of the four Mount Sinai sites in Manhattan
* a family caregiver willing to enroll
* a residence in Manhattan where they are currently living (not in a long-term care facility)
* capacity to consent or a legal representative available to provide consent
* fluency in English or Spanish, or their legal representative must be fluent in English or Spanish
* age \>64.
Exclusion Criteria
* Does not reside in Manhattan outside of long-term care facility
* Does not have fluency in English or Spanish Doesn't
65 Years
ALL
No
Sponsors
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National Institute on Aging (NIA)
NIH
Icahn School of Medicine at Mount Sinai
OTHER
Responsible Party
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Laura Gelfman
Professor
Principal Investigators
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Laura P Gelfman, MD, MPH
Role: PRINCIPAL_INVESTIGATOR
Icahn School of Medicine at Mount Sinai
Locations
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Ichan School of Medicine at Mount Sinai
New York, New York, United States
Countries
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Central Contacts
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Facility Contacts
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Christian Esspino
Role: primary
Other Identifiers
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GCO 19-1232
Identifier Type: -
Identifier Source: org_study_id