Improving Palliative Care Through Teamwork

NCT01990742 | Completed Results

• 1 other identifier: PCORI-641
• Study Type: interventional
• Target: 31
• Locations: 1 country
• Sites: 1

Brief Summary

One in three Americans dies in a nursing home (NH) or in a hospital, shortly following transfer from a long-term care facility. The proportion of deaths occurring in NHs is projected to increase to 40% by 2020. Excellence in palliative and end-of-life (EOL) care must become a priority for these long-term care institutions. However, findings from NHs point to high incidence of pain and poor management of other symptoms and excessive reliance on hospitalizations, indicating inadequate EOL care quality. Expert opinion and research have suggested that poor EOL quality in NHs may be due to lack of palliative care training among staff and absence of EOL care protocols or guidelines, but research demonstrating that attention to these factors improves outcomes is absent. While dedicated care teams have been shown to improve outcomes for NH residents in need of specialized care, the impact of palliative care teams in improving resident outcomes has remained largely unstudied and untested. This will be the first randomized controlled trial to evaluate the impact of palliative care teams (PCTeam) on resident and staff outcomes, and care processes, in NHs. Our objective is to demonstrate, using a randomized controlled trial design and a difference in difference analytic approach, that nursing home-based palliative care practice guidelines implemented through PCTeams will improve quality of care processes and outcomes for residents at the end of life. We will adapt existing palliative care guidelines for EOL care, endorsed by the National Quality Forum (NQF), to the NH environment, deploy the adapted practice guidelines through a PCTeam model, and evaluate the effectiveness of this intervention on resident EOL outcomes and staff care processes and outcomes. The specific aims (SA) will address the following questions: SA 1: Is PCTeam intervention effective in improving NH residents' EOL outcomes? SA 2: Is PCTeam intervention effective in improving NH staff EOL care processes and outcomes? In the context of these specific aims we will test the following hypotheses: H1: Residents in NHs in the intervention arm, compared to the control, will achieve better EOL risk-adjusted outcomes and care processes with regard to:

• Pain
• Dyspnea
• Depression
• In-hospital deaths
• Hospitalizations
• Advance directives H2: Direct care staff in NHs in the intervention arm, compared to the control, will achieve better EOL processes and outcomes measured by:
• Assessment of EOL symptoms
• Delivery of EOL care
• Communication/coordination among providers
• Communication with residents/families
• Teamwork effectiveness
• Staff satisfaction H3: Family caregivers of decedent residents in the intervention NHs, compared to the control, will report receiving more patient and family centered care as measured by higher levels of satisfaction with:
• Shared decision making between providers, the patient and the family
• Care that is respectful of the patient wishes and dignity
• Attention to the emotional and spiritual needs of the family. 31 NHs in upstate New York have been recruited for the study (letters of support). Stakeholders include residents, family members, staff, policy makers, and others. The intervention will deploy theTeamSTEPPS, a team development model created by the Department of Defense and the Agency for Healthcare Research and Quality.

Conditions

Palliative Care

Outcome Measures

Primary Outcomes (1)

• Hospital Site of Death: Number of Decedents Cared for in an Enrolled and Assigned NH Facility, Who Were Transferred to a Hospital and Died in the Hospital During the Study Period

  This outcome measure, Hospital Site of Death, assesses whether death occured in a nursing home or in a hospital following transfer from the nursing home, among nursing home residents who were cared for in an enrolled facility.

  1 year

Secondary Outcomes (1)

• Hospitalizations

  The last 90 days of life

Other Outcomes (1)

• Number of Nursing Home Residents in Moderate-to-severe Pain

  up to 6 months prior to death

Study Arms (2)

Palliative Care Team (PCTeam)

EXPERIMENTAL

Palliative care teams will be established and will round with residents in the intervention homes.

Behavioral: Palliative Care Team (PCTeam)

Standard care

NO INTERVENTION

Usual care will be provided to residents in the control homes.

Interventions

Palliative Care Team (PCTeam) BEHAVIORAL

Palliative care teams will be established and will round with residents in the intervention nursing homes.

Palliative Care Team (PCTeam)

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• long-stay nursing home residents (\>90 days)

You may not qualify if:

• rehabilitative, post-acute residents (\<90 days)

Sponsors & Collaborators

• University of Rochester: lead
• University of California, Irvine: collaborator

Study Sites (1)

University of Rochester School of Medicine and Dentistry

Rochester, New York, 14642, United States

Location

Related Publications (1)

• Ryan RE, Connolly M, Bradford NK, Henderson S, Herbert A, Schonfeld L, Young J, Bothroyd JI, Henderson A. Interventions for interpersonal communication about end of life care between health practitioners and affected people. Cochrane Database Syst Rev. 2022 Jul 8;7(7):CD013116. doi: 10.1002/14651858.CD013116.pub2.

  PMID: 35802350 DERIVED

Limitations and Caveats

1. We were unable to distinguish the relative importance of the individual intervention components. 2. Our findings were confined to regional facilities, and may not be generalized elsewhere.

Results Point of Contact

• Title: Dr. Helena Temkin-Greener
• Organization: University of Rochester

Helena_Temkin-Greener@urmc.rochester.edu

585-275-8713

Study Officials

• Helena Temkin-Greener, PhD

  University of Rochester

  PRINCIPAL INVESTIGATOR

Publication Agreements

• PI is Sponsor Employee: No
• Restrictive Agreement: No

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Professor

Study Record Dates

• First Submitted: September 23, 2013
• First Posted: November 21, 2013
• Study Start: September 27, 2013
• Primary Completion: December 31, 2016
• Study Completion: April 1, 2017
• Last Updated: September 17, 2018
• Results First Posted: August 20, 2018

Record last verified: 2018-08

Locations

US (1)