In this study, participants will be randomly assigned to receive either the intervention or control treatment for up to 6 months. Participants in the intervention group will receive care from an intensive geriatric service worker (IGSW), who will help the participant: (i) Coordinate community resources and actively support participants' instrumental activities of daily living (IADLs) (e.g., linking participants with Meals-on-Wheels, taking participants to appointments) (ii) Advocate for support from home care for completing activities of daily living (ADLs) (iii) Implement patients' prioritized treatment recommendations made by healthcare professionals (e.g., supporting patients to purchase and install home safety equipment because this aligns with their values and preferences). Participants in the control group will receive their usual care, along with a booklet containing information about locally available resources, such as those related to meal preparation, grocery delivery, housekeeping, pharmacies that deliver medicines, home care, and Wheel-Trans. We are interested in learning about the number and demographic characteristics of participants we will be able to recruit to the study, who will remain in the study and who will be adherent to their prioritized treatment recommendations. We are also interested in learning about changes in participants' quality of life, proportion of IADLs being completed independently or with support, emergency department visit rate, and hospitalization rate at 3 and 6 months.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
SUPPORTIVE_CARE
Masking
SINGLE
Enrollment
60
Participants in the intervention group will receive care from an intensive geriatric service worker (IGSW), who will help the participant: (i) Coordinate community resources and actively support participants' instrumental activities of daily living (IADLs) (e.g., linking participants with Meals-on-Wheels, taking participants to appointments) (ii) Advocate for support from home care for completing activities of daily living (ADLs) (iii) Implement patients' prioritized treatment recommendations made by healthcare professionals (e.g., supporting patients to purchase and install home safety equipment because this aligns with their values and preferences).
Participants will be e-mailed or mailed a booklet containing information about locally available resources including (1) meal preparation, (2) grocery delivery, (3) housekeeping, (4) pharmacies that deliver medications, (5) home care, and (6) Wheel-Trans. Participants will receive a scripted phone call from the study research coordinator one and three months after study enrolment to see if they have questions about the booklet material.
Implementation Feasibility
The number of participants (i) recruited (over the entire 12-month recruitment period and per month), (ii) retained (remain in the IGSW care model until prioritized recommendations are implemented, are discharged from the program because they are admitted to a retirement or LTC home, or complete the intervention; number of participants in the control group who provide follow-up data at 3 and 6 months) (iii) fully adherent to patients' prioritized recommendations during the trial period (% full adherence to \[a\] all prioritized recommendations, \[b\] \>75% of prioritized recommendations, and \[c\] ≥1 prioritized recommendation at 3 and 6 months) and (iv) sustained linkages to community agencies to provide ADL and IADL support (number of participants with linkages to \[a\] all community agencies, \[b\] ≥1 community agency at 3 and 6 months).
Time frame: Between 3 months to 1 year
Quality of Life
Change in quality of life will be measured with the EQ-5D-5L
Time frame: 3 and 6 months
Proportion of IADLs being completed independently or with support
Time frame: 3 and 6 months
Emergency department visit rate
Time frame: 3 and 6 months
Hospitalization rate
Time frame: 3 and 6 months
Long-term care home admission rate
Time frame: 3 and 6 months
Length of hospitalization
This will be measured for study participants admitted to hospital.
Time frame: 6 months
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