Participants in Electronic Frailty Integrated with Social Needs (eFRIEND) will randomize to receive regularly scheduled in-person and telehealth contacts with a community health worker (CHW) or continue to receive standard of care. The purpose of this research is to use CHW to help older adults because there may be some resources that could benefit them that they are not aware of or for which they need help applying.
The study team will conduct a pragmatic randomized pilot trial of a CHW-led hybrid in-person/telehealth program pathway (eFRIEND) for frail older adults. Using Zelen's effectiveness design, the study team will identify eligible frail older adults via the Electronic Health Record (EHR). Eligible participants will be randomized to the eFRIEND pathway or usual care. The study team will randomize 2050 older adults (1050 to eFRIEND, 1000 to usual care), with the randomization stratified by primary care clinic. Eligible participants randomized to the eFRIEND pathway will be contacted by phone to discuss study procedures and obtain verbal informed consent. eFRIEND comprises a 6-month intervention. All CHW will be certified and have participated in the North Carolina Community Health Worker Standardized Core Competency Training. CHW are trusted members of the community and are utilized as part of routine care to assist patients. At the first visit, the CHW will assess if the participants have any unmet social and/or functional needs (baseline survey). The frequency and amount of time of each point of contact will be at the discretion of the CHW.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
SUPPORTIVE_CARE
Masking
NONE
Enrollment
2,050
eFRIEND is a 6-month CWH-led intervention. All CHW will be part of the research team to ensure successful recruitment and interaction with patients, and all CHW will be certified and have participated in the North Carolina Community Health Worker Standardized Core Competency Training.
Routine treatment in primary care
Atrium Health Wake Forest Baptist Health
Winston-Salem, North Carolina, United States
Number of ED Visits or Inpatient Hospitalizations
Healthcare encounters will be tracked using the Electronic Health Record (EHR)
Time frame: Month 6
Number of ED Visits or Inpatient Hospitalizations
Healthcare encounters will be tracked using the Electronic Health Record (EHR)
Time frame: Month 12
Number of Completed Medicare Annual Wellness Visits (AWVs)
Determined through data extraction from the EHR
Time frame: Month 6 and Month 12
Usage of Advance Care Planning (ACP)
Total number of patients who completed ACP based on billing codes (99497 and 99498) from the EHR. The listed billing codes indicate that ACP has been completed at a patient's appointment.
Time frame: Month 6 and Month 12
Acceptability of Program
Survey by clinicians at the participating sites. Mean score on the program acceptability survey Acceptability survey is comprised of the Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM). Scores range from 12-60, with higher scores indicating greater acceptability.
Time frame: Month 6 and Month 12
Participant Uptake of Home Health Services--Total Number
Care at home survey measuring if patient received home health services with yes or no answer. Total number of participants who say yes.
Time frame: Month 6 and Month 12
Participant Uptake of Home Health Services--Proportion
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Care at home survey measuring if patient received home health services with yes or no answer. Proportion of participants who say yes.
Time frame: Month 6 and Month 12
Proportion of eligible patients who interact with CHW
Shows feasibility of patient recruitment.
Time frame: Month 6 and Month 12
Number of Annual Wellness Visits (AWV)s
Time frame: Month 6 and Month 12
Percentage of Participants who Report Food Insecurity--Total Number
Collected by yes/no response on questionnaire. Subjects who positively report food insecurity are included.
Time frame: Month 6 and Month 12
Percentage of Participants who Report Food Insecurity--Proportion
Collected by yes/no response on questionnaire. Subjects who positively report food insecurity are included.
Time frame: Month 6 and Month 12
Percentage of Participants who Report Housing Instability--Total Number
Collected by yes/no response on questionnaire. Subjects who positively report housing instability are included.
Time frame: Month 6 and Month 12
Percentage of Participants who Report Housing Instability--Proportion
Collected by yes/no response on questionnaire. Subjects who positively report housing instability are included.
Time frame: Month 6 and Month 12
Percentage of Participants who Report Lack of Transportation--Total Number
Collected by yes/no response on questionnaire. Subjects who positively report lack of transportation are included.
Time frame: Month 6 and Month 12
Percentage of Participants who Report Lack of Transportation--Proportion
Collected by yes/no response on questionnaire. Subjects who positively report lack of transportation are included.
Time frame: Month 6 and Month 12
Percentage of Participants who Report Use of Social Services--Total Number
Collected by yes/no response on questionnaire. Subjects who positively report use of social services are included.
Time frame: Month 6 and Month 12
Percentage of Participants who Report Use of Social Services--Proportion
Collected by yes/no response on questionnaire. Subjects who positively report use of social services are included.
Time frame: Month 6 and Month 12
Percentage of Participants who Report Use of Home Health Services--Total Number
Collected by yes/no response on questionnaire. Subjects who positively report use of home health services are included.
Time frame: Month 6 and Month 12
Percentage of Participants who Report Use of Home Health Services--Proportion
Collected by yes/no response on questionnaire. Subjects who positively report use of home health services are included.
Time frame: Month 6 and Month 12
Percentage of Participants who Report Social Isolation--Total Number
Collected by yes/no response on questionnaire. Subjects who positively report social isolation are included.
Time frame: Month 6 and Month 12
Percentage of Participants who Report Social Isolation--Proportion
Collected by yes/no response on questionnaire. Subjects who positively report social isolation are included.
Time frame: Month 6 and Month 12