Loading search results
C4
An Inter-Disciplinary Outpatient Care Model Providing Comprehensive Geriatric Assessment, Care-Coordination and Co-management to High Need High Risk Veterans Meeting HBPC Criteria
Sponsor study identifier
observational
206
1 country
1
Study Start
April 16, 2018
Actual (reported)Primary Completion
March 31, 2022
Actual (reported)Study Completion
March 31, 2022
Actual (reported)The Department of Veterans Affairs' (VA) Home Based Primary Care (HBPC) program provides comprehensive care to its sickest, frailest Veterans with multiple complex chronic diseases. The HBPC program is a resource intensive non-institutional care program where Veterans, who are not able to receive primary care at the VA, are closely monitored and care is provided using an interdisciplinary team that coordinates the care through multi-professional home visits. The Geriatric Extended Care recommended that Miami Veteran Affairs Healthcare System (VAHS) HBPC enroll from a list of over 2,000 pre-identified High Need High Risk (HNHR) Miami Veterans for whom HBPC enrollment would have a high likelihood of clinical and economic benefits. HNHR Veterans have the greatest need for care but face the steepest challenges with access. However, despite best of intentions, the Miami HBPC program does not have the capacity to enroll the large numbers of Veterans on this new HNHR list. Therefore, innovative strategies are needed to provide appropriate needed care for this HNHR Veteran population. Goal: Maintain older Veterans in their homes for as long as possible. Aims: Design and pilot test an evidence-based, outpatient, Comprehensive geriatric assessment, Care plan based, Care-coordination, Co-management (C4) model, for 100 HBPC eligible HNHR older Veterans who are not enrolled in the HBPC program. The investigators will develop, implement and evaluate a VA model to provide a comprehensive geriatric assessment of HNHR Veterans, design a structured care plan that includes care coordination to link their needs to appropriate referrals, home and community based services, monitor and coach patients and caregivers, and coordinate their care across VA and non-VA providers and settings. Objectives:
Registry-reported information. Elapsed time and enrollment totals alone do not measure study progress or recruitment pace.
March 31, 2022
Actual (reported)Click on a node to explore related trials.
Some registry-reported names shown below are not yet linked in this graph.
Dates and qualifiers reported by the registry. Estimated dates do not confirm that a milestone has occurred.
April 16, 2018
Actual (reported)March 5, 2019
Actual (reported)April 15, 2021
Actual (reported)March 31, 2022
Actual (reported)March 31, 2022
Actual (reported)Changes in FRAIL score
The FRAIL scale (Fatigue, Resistance, Ambulation, Illnesses, \& Loss of Weight) is a simple questionnaire of frailty syndrome for older adults. If a patient scores 3-5 points over a total score of 5 points in the FRAIL, the patient is considered as frail. Change from baseline score and 6 months.
5 minutes
Change in Montreal Cognitive Assessment (MOCA)
Rapid screen of cognitive abilities designed to detect mild cognitive dysfunction consisting of 16 items and 11 categories assessing multiple cognitive domains. No cognitive impairment \>=25 Mild cognitive impairment = 20-24 Severe cognitive impairment \< 20. Change from baseline score and 6 months.
10 minutes
Veterans with complex medical conditions that may need more help. This intervention will provide extra care coordination after a complete assessment of their health. Research team will assess veteran's memory, physical function, strength, balance, and from there, find the areas they need the most help with and coordinate services at home. This is in addition to their regular primary care provider.
Veterans receiving standard of care
1. Comprehensive Geriatric Assessment (3 visits with a geriatrician alternating with 3 primary provider visits over 6 months) 2. Care Planning with Interdisciplinary Team 3. Care coordination 4. Co-management with Primary care 5. Social work needs assessment 6. Patient-centered telehealth using phone, home telehealth, patient portal, Video 7. Transportation provided for all visits 8. Referral to Geriatric primary care clinic and mental health per Veteran need 9. Goals of Care and Veteran preferences conversation 10. Educate primary care providers about HNHR population, home and community based services, collaboration
High Need High Risk Veterans in Miami Medical Center area
Miami VA Healthcare System
Miami, Florida, 33125, United States
Stuti Dang, MD,MPH
Miami VA Healthcare System
206 participants (actual enrollment reported by the registry).
First Submitted
March 5, 2019
First Posted
April 15, 2021
Study Start
April 16, 2018
Actual (reported)Katz Index of Independence in Activities of Daily Living
10 minutes
Lawton-Brody Instrumental Activities of Daily Living Scale
10 minutes
Detection of symptoms of depression
5 minutes
Change in number of clinic visits
6-months
Change in number of hospital admissions
6-months
No intervention or treatment will be provided.
Registry-reported names are shown in full. Names without a link have not yet been matched to a Syfrah profile.
Contact the study team to confirm eligibility.
Primary Completion
March 31, 2022
Actual (reported)Study Completion
March 31, 2022
Actual (reported)Last Updated
August 23, 2024
Record last verified: 2024-08
Download the complete ClinicalTrials.gov record imported by Syfrah, including fields not shown in this page. The registry may contain a newer revision.
Source: ClinicalTrials.gov.
JSON downloads include source attribution and retrieval details alongside the unchanged original record or the separately normalized values.
Source retrieved: