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

Brigham and Women's Hospital194 enrolled

Overview

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.

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.

Study Type

INTERVENTIONAL

Allocation

NON_RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

NONE

Enrollment

194

Conditions

Failure to Thrive

Interventions

TrainingBEHAVIORAL

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.

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

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

Locations (1)

Brigham and Women's Hospital

Boston, Massachusetts, United States

Outcomes

Primary Outcomes

Percentage of eligible patients with documented goals of care conversations

For patients whose death falls during the study period, the percentage of goals of care conversations completed and documented in the electronic medical record by clinicians in the intervention group and the control group. A completed conversation is defined by key elements being documented regarding goals of care in the patient's medical record.

Time frame: from date of determination of eligibility to date of death death during the study period, assessed for up to 18 months

Secondary Outcomes

Median number of days before death of first documented goals of care conversation

For all patients whose death falls during the study period, the median number of days from the date of the first documented goals of care conversation to date of death in both the intervention and the control group.

Time frame: from date of determination of eligibility to date of death during the study period, assessed for up to 18 months

Percentage of eligible patients with more comprehensive documentation of goals of care before death

For all patients whose death falls during the study period, the percentage of patients with more comprehensive goals of care documentation before death in both the intervention group and the control group. More comprehensive is defined as documentation of a goals of care conversation that addresses more than code status only and will be evaluated for completeness in containing more key elements of a Serious Illness Care Guide conversation.

Time frame: from date of determination of eligibility to date of death during study period, assessed for up to 18 months

Data from ClinicalTrials.gov

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