Enhancing Care Coordination: Hospital to Home for Cognitively Impaired Older Adults and Their Caregivers

NCT00294307 | Completed

• 1 other identifier: R01AG023116
• Study Type: observational
• Target: 814
• Locations: 1 country
• Sites: 3

Brief Summary

Aim 1. To compare across three hospital sites the effects on health and cost outcomes observed by the following three interventions, each designed to enhance adaptation and improve outcomes of hospitalized cognitively impaired elders and their caregivers:

1. 1.augmented standard care (ASC) - standard hospital and, if referred, home care plus early identification of CI during the patients' hospitalization by trained registered nurses (RNs) with immediate feedback to patients' primary nurses, attending physicians and discharge planners;
2. 2.resource nurse care (RNC) - standard hospital and, if referred, home care plus early identification of CI during the patient's hospitalization by trained RNs and hospital care by RNs trained in the use of expert clinical guidelines developed to enhance the care management of hospitalized cognitively impaired elders and to facilitate their transition from hospital to home; or,
3. 3.advanced practice nurse care (APNC) - standard hospital care plus transitional (hospital to home) care substituting for standard home care and provided by APNs with advanced training in the management of CI patients using an evidence-based protocol designed specifically for this patient group and their caregivers.

Conditions

Dementia; Dementia, Vascular; Alzheimer Disease; Delirium, Dementia, Amnestic, Cognitive Disorders; Lewy Body Disease; Mild Cognitive Impairment

Keywords

Nursing Models of Care; Collaborative Care; Care Management; Transitional Care; Advanced Practice Nurse Care Interventions; Cognitive Impairment; Dementia; Delirium

Outcome Measures

Primary Outcomes (4)

• Patient - Function

  Basic Activities of Daily Living

  At hospital admission and at 2-, 6-, 12-, and 26-weeks post-discharge

• Caregiver - Burden

  At hospital admission and at 2-, 6-, 12-, and 26-weeks post-discharge

• Patient - Health Care Costs

  Through 6 months

• Patient - Time to first rehospitalization or death; total rehospitalization days

  Time calculated from index hospital discharge to first rehospitalization or death. Total days rehospitalized through six months.

  From index hospital discharge through 6 months

Secondary Outcomes (8)

• Patient - Total rehospitalizations

  From index hospital discharge through 6 months

• Patient - Cognitive Function

  At hospital admission and at 2-, 6-, 12-, and 26-weeks post-discharge

• Patient - Care Management

  From enrollment through 6 months

• Patient - Symptoms (Physical and depressive symptoms)

  At hospital admission and at 2-, 6-, 12-, and 26-weeks post-discharge

• Patient - Neuropsychiatric Behaviors

  At hospital admission and at 2-, 6-, 12-, and 26-weeks post-discharge

Study Arms (3)

Advanced Practice Nurse Care (APNC)

Hospital to Home

Behavioral: Advanced Practice Nurse Care (APNC)

Augmented Standard Care (ASC)

Hospital only

Behavioral: Augmented Standard Care (ASC)

Resource Nurse Care (RNC)

Hospital only

Behavioral: Resource Nurse Care (RNC)

Interventions

Augmented Standard Care (ASC) BEHAVIORAL

Standard hospital care and, if referred, home care plus early identification of CI during the patients' hospitalization by trained research assistants with immediate verbal feedback and documentation to patients' primary nurses, attending physicians and discharge planners \[low intensity\];

Augmented Standard Care (ASC)

Resource Nurse Care (RNC) BEHAVIORAL

Standard hospital and, if referred, home care plus early identification of CI during the patient's hospitalization (ASC) and hospital care by RNs trained in the use of expert clinical guidelines developed to enhance the care management of hospitalized cognitively impaired elders and to facilitate their transition from hospital to home \[medium intensity\];.

Resource Nurse Care (RNC)

Advanced Practice Nurse Care (APNC) BEHAVIORAL

Standard hospital care plus ASC and transitional care starting in the hospital and substituting for standard home care and provided by Advanced Practice Nurses (APNs) with advanced training in the management of CI patients using an evidence-based protocol designed specifically for this patient group and their caregivers \[high intensity\].

Advanced Practice Nurse Care (APNC)

Eligibility Criteria

• Age: 65 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Older Adult (65+)
• Sampling Method: Non-Probability Sample

Study Population

Hospitalized community dwelling older adults with cognitive impairment and a caregiver

You may qualify if:

• Age \>= 65 and older
• Speaks English
• Resides within 30 miles of admitting hospital site
• Admitted from home to one of three hospital sites
• a documented history of pre-existing dementia in their medical records or pre-screen positive for cognitive impairment using our Pre-Screen Process.
• a primary caregiver (knowledgeable informant), defined as the spouse, family member, partner or friend, who will provide support following discharge to home and is reachable by telephone.

You may not qualify if:

• End Stage Disease
• Active untreated substance abuse or psychiatric conditions
• Primary cancer diagnosis (active treatment)

Sponsors & Collaborators

• University of Pennsylvania: lead
• National Institute on Aging (NIA): collaborator

Study Sites (3)

Pennsylvania Hospital

Philadelphia, Pennsylvania, 19102, United States

Location

Hospital of the University of Pennsylvania

Philadelphia, Pennsylvania, 19104, United States

Location

Penn-Presbyterian Medical Center

Philadelphia, Pennsylvania, 19104, United States

Location

Related Publications (9)

• Naylor MD, Hirschman KB, Bowles KH, Bixby MB, Konick-McMahan J, Stephens C. Care coordination for cognitively impaired older adults and their caregivers. Home Health Care Serv Q. 2007;26(4):57-78. doi: 10.1300/j027v26n04_05.

  PMID: 18032200 BACKGROUND

• Naylor MD, Stephens C, Bowles KH, Bixby MB. Cognitively impaired older adults: from hospital to home. Am J Nurs. 2005 Feb;105(2):52-61; quiz 61-2. doi: 10.1097/00000446-200502000-00028. No abstract available.

  PMID: 15674058 BACKGROUND

• McCauley K, Bradway C, Hirschman KB, Naylor MD. Studying nursing interventions in acutely ill, cognitively impaired older adults. Am J Nurs. 2014 Oct;114(10):44-52. doi: 10.1097/01.NAJ.0000454851.22018.5d.

  PMID: 25251126 BACKGROUND

• Shankar KN, Hirschman KB, Hanlon AL, Naylor MD. Burden in caregivers of cognitively impaired elderly adults at time of hospitalization: a cross-sectional analysis. J Am Geriatr Soc. 2014 Feb;62(2):276-84. doi: 10.1111/jgs.12657. Epub 2014 Feb 6.

  PMID: 24502827 BACKGROUND

• Hirschman KB, Paik HH, Pines JM, McCusker CM, Naylor MD, Hollander JE. Cognitive Impairment among Older Adults in the Emergency Department. West J Emerg Med. 2011 Feb;12(1):56-62.

  PMID: 21691473 BACKGROUND

• Bradway C, Trotta R, Bixby MB, McPartland E, Wollman MC, Kapustka H, McCauley K, Naylor MD. A qualitative analysis of an advanced practice nurse-directed transitional care model intervention. Gerontologist. 2012 Jun;52(3):394-407. doi: 10.1093/geront/gnr078. Epub 2011 Sep 9.

  PMID: 21908805 RESULT

• Naylor MD, Hirschman KB, Hanlon AL, Bowles KH, Bradway C, McCauley KM, Pauly MV. Comparison of evidence-based interventions on outcomes of hospitalized, cognitively impaired older adults. J Comp Eff Res. 2014 May;3(3):245-57. doi: 10.2217/cer.14.14.

  PMID: 24969152 RESULT

• Naylor MD, Hirschman KB, Hanlon AL, Bowles KH, Bradway C, McCauley KM, Pauly MV. Effects of alternative interventions among hospitalized, cognitively impaired older adults. J Comp Eff Res. 2016 May;5(3):259-72. doi: 10.2217/cer-2015-0009. Epub 2016 May 5.

  PMID: 27146416 RESULT

• Pauly MV, Hirschman KB, Hanlon AL, Huang L, Bowles KH, Bradway C, McCauley K, Naylor MD. Cost impact of the transitional care model for hospitalized cognitively impaired older adults. J Comp Eff Res. 2018 Sep;7(9):913-922. doi: 10.2217/cer-2018-0040. Epub 2018 Sep 11.

  PMID: 30203668 RESULT

MeSH Terms

Conditions

Dementia; Dementia, Vascular; Alzheimer Disease; Neurocognitive Disorders; Lewy Body Disease; Cognitive Dysfunction; Delirium

Condition Hierarchy (Ancestors)

Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Mental Disorders; Cerebrovascular Disorders; Intracranial Arteriosclerosis; Intracranial Arterial Diseases; Leukoencephalopathies; Arteriosclerosis; Arterial Occlusive Diseases; Vascular Diseases; Cardiovascular Diseases; Tauopathies; Neurodegenerative Diseases; Parkinsonian Disorders; Basal Ganglia Diseases; Movement Disorders; Synucleinopathies; Cognition Disorders; Confusion; Neurobehavioral Manifestations; Neurologic Manifestations; Signs and Symptoms; Pathological Conditions, Signs and Symptoms

Study Officials

• Mary D Naylor, PhD

  University of Pennsylvania

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: observational
• Observational Model: COHORT
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: February 16, 2006
• First Posted: February 20, 2006
• Study Start: February 1, 2006
• Primary Completion: July 1, 2010
• Study Completion: August 1, 2012
• Last Updated: February 5, 2019

Record last verified: 2019-02

Locations

US (3)