Improving How People Living With Dementia Are Selected for Care Coordination

NCT05651308 | Completed Results DMC

• 3 other identifiers: 22-100252923U54AG063546-03Subaward 00002102
• Study Type: interventional
• Target: 385
• Locations: 1 country
• Sites: 1

Brief Summary

Many people living with dementia (PLWD) and their care partners may benefit from the assistance of a care coordinator, a member of the medical team who facilitates communication among all the people involved. However, care coordinators' time is limited, and there is uncertainty about which patients should be selected to receive their help. This pragmatic clinical trial embedded in an accountable care organization will determine the comparative effectiveness of two approaches for assigning care coordinators to PLWD.

Conditions

Dementia

Keywords

care coordination; accountable care organization

Outcome Measures

Primary Outcomes (1)

• Number of Emergency Department Visits or Hospital Admissions

  Occurrence of an emergency department visit or hospital admission, as measured in Medicare claims

  Over 12 months (beginning 1 month after the start of care coordination)

Secondary Outcomes (4)

• Acceptability

  Up to 1 year

• Appropriateness

  Up to 1 year

• Fidelity

  Up to 1 year

• Efficiency

  Up to 1 year

Study Arms (2)

Intervention

EXPERIMENTAL

The intervention group will assign care coordinators to PLWD based on perceived need for assistance with care coordination. Perceived need will be measured through a proxy's responses to a previously validated telephone survey on perceptions of care coordination.

Behavioral: Care coordination delivered based on perceived need

Control

ACTIVE COMPARATOR

Usual care assigns patients to care coordinators in response to a discharge from a hospital or a direct referral from a physician.

Behavioral: Care coordination delivered based on usual care (e.g. discharge from hospital)

Interventions

Care coordination delivered based on perceived need BEHAVIORAL

If proxies for patients in intervention group report on the survey that they experience difficulty coordinating care among the patients' providers, the patient will be selected for care management services. Those services will attempt to address the problems with care coordination that the proxy reported.

Intervention

Care coordination delivered based on usual care (e.g. discharge from hospital) BEHAVIORAL

If a patient is discharged from a hospital, the patient will be selected for care management services.

Control

Eligibility Criteria

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

You may qualify if:

• Medicare beneficiaries ≥65 years old who:
• Are attributed to the NewYork Quality Care accountable care organization by Medicare,
• Have dementia (as measured in claims using the Bynum standard 1-year definition),
• Reside in the community, and
• Had fragmented ambulatory care in the previous 12 months (defined as a reversed Bice-Boxerman Index greater than or equal to the median score for this population, using Medicare claims)

You may not qualify if:

• Those who reside in long-term care or nursing home facilities (based on addresses in Medicare claims), or
• Enrolled in home hospice

Sponsors & Collaborators

• Weill Medical College of Cornell University: lead
• National Institute on Aging (NIA): collaborator
• Brown University: collaborator

Study Sites (1)

New York Presbyterian Hospital - Weill Cornell Medicine

New York, New York, 10065, United States

Location

MeSH Terms

Conditions

Dementia

Condition Hierarchy (Ancestors)

Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Neurocognitive Disorders; Mental Disorders

Results Point of Contact

• Title: Lisa M. Kern, MD, MPH
• Organization: Weill Cornell Medicine

lmk2003@med.cornell.edu

646-962-5889

Study Officials

• Lisa M Kern, MD, MPH

  Weill Medical College of Cornell University

  PRINCIPAL INVESTIGATOR

• Vincent Mor, PhD

  Brown University

  STUDY DIRECTOR

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: SPONSOR

Study Record Dates

• First Submitted: December 5, 2022
• First Posted: December 15, 2022
• Study Start: December 5, 2022
• Primary Completion: April 30, 2024
• Study Completion: April 30, 2024
• Last Updated: March 13, 2025
• Results First Posted: March 13, 2025

Record last verified: 2025-02

Data Sharing

• IPD Sharing: Will not share

Locations

US (1)