Implementation of a Telehealth Palliative Care Model for Persons With Dementia

University of Maryland, Baltimore16 enrolled

Overview

Grounded in the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) Model, this study will assess the implementation outcomes of the Nurse Practitioner (NP) delivered telehealth Palliative Care Consultation in Post-Acute Care (PCC-PAC) intervention for persons living with dementia (PLWD) and their care-partners newly admitted to nursing homes (NHs) for post-acute care.

This single arm embedded pragmatic pilot clinical trial will provide data to assess the implementation outcomes of the Nurse Practitioner (NP) delivered telehealth Palliative Care Consultation in Post-Acute Care (PCC-PAC) intervention among 30 persons living with dementia (PLWD) and their care-partners newly admitted to one nursing homes (NH) for post-acute care.

Study Type

INTERVENTIONAL

Allocation

NON_RANDOMIZED

Purpose

SUPPORTIVE_CARE

Masking

NONE

Enrollment

Conditions

Palliative Care Dementia

Interventions

Palliative Care ConsultationOTHER

The PC provider conducts the structured PCC-PAC via videoconference or telephone with the PLWD and/or their care partner and the social work (SW) champion in the NH. The SW and PC provider will set up a mutually agreed upon consultation day/time with the PLWD and/or care partner, within 5 business days of NH admission and follow up visits will occur no more than 30 days later (if needed).

Eligibility

Sex: ALLMin age: 60 YearsHealthy volunteers:

Medical Language ↔ Plain English

Inclusion Criteria: Stakeholders: * (1) PC provider * (2) Social Work (SW) NH champions * (3) post-acute care unit nursing staff and providers (including medical directors) * (4) NH leadership, information technology staff * (5) PLWD and their care partner(s). Person Living with Dementia (PLWD) * documented dementia diagnosis * admitted for post-acute care * age ≥ 60 years * if unable to participate in a conversation or lacking capacity to make healthcare decisions as determined by the NH staff/providers, a care partner who can act as a surrogate decision maker in the PCC-PAC. Exclusion Criteria: Stakeholders: -PLWD who receives the intervention PLWD: * planned discharge within 48 hours of screening * currently receiving hospice care

Locations (1)

Collingswood Rehabilitation and Healthcare Center

Rockville, Maryland, United States

Outcomes

Primary Outcomes

Adherence to Skilled Nursing Facility (SNF)-PCC Recommendations

Investigators will determine a recommendation adherence score after each participants' encounter. Each recommendation will be assigned 2 points, then will define full (2 points), partial (1 point) and no adherence (0 point) to each recommendation. Investigators will sum the points for each SNF-PCC recommendation and use this as the denominator. Investigators will sum each recommendation with full, partial, no adherence and use this as the numerator. The fraction will be converted to a percentage ranging from 0-100% reflecting the recommendation adherence score.

Time frame: 30 days post admission

Secondary Outcomes

Number of Hospitalizations

Number of hospitalization(s)

Time frame: 30 days post admission

Data from ClinicalTrials.gov

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