Nurse Led Telephonic Care

点击翻译按钮获取中文摘要

PROJECT SUMMARY The emergency department (ED) is often the care setting of last resort, and is ill suited to provide care for people living with dementia (PLWD) and their care partners. Many ED visits, which are for ambulatory-care- sensitive or acute exacerbations of chronic conditions, pain, behavioral and psychological symptoms of dementia (BPSD), and care partner strain are addressable if intervened upon in the community. Significant inequity in access to effective outpatient or home-based care further exacerbates who unnecessarily ends up in the ED. ED visits are also a significant indicator for serious illness in PLWD; 43.1% will have subsequent ED visits and 31.9% will die within one year. Telephonic nurse-led, interdisciplinary transitional and palliative care is a cost-effective, patient centered modality shown to both reduce inequities and ED visits. Studies in both palliative care populations and earlier stages of AD/ADRD without serious illness showed efficacy. However, this work has not focused on those living with Alzheimer’s Disease and Alzheimer’s Disease-Related Dementias (AD/ADRD) who are also seriously ill, on large scale “real-world” embedded pragmatic clinical trials, or with a focus on the ED as site of triggering telephonic care. This project will implement Aliviado Dementia Care-Telephonic Edition, an evidence-based nurse-led telephonic transition and palliative care intervention tested end-to-end and widely disseminated in other modalities. The intervention will follow PLWD for 6-months, and focus on care transitions, assessing and managing BPSD, care partner strain, social determinants of health and social needs, and conversations about serious illness. In this study, the nurse-led telephonic intervention will first be optimized for use in conjunction with the two other interventions used in this proposal (ED Care Redesign and Community Paramedic-led Transitions) in two EDs to ensure effective coordination when multiple interventions are used. This optimization will follow a user-centered design process and engage a wide spectrum of stakeholders in coordination with administrative and implementation cores (Aim 1). We will then conduct a 3-arm embedded pragmatic multifactorial cluster randomized trial that uses Medicare claims data to test whether nurse-led telephonic care for PLWD alone and in concert with the other interventions reduces ED visits and hospitalizations, and increases the number of healthy days at home (Aim 2). We will implement the intervention in 40 EDs in the larger pragmatic trial, tested alone and in conjunction with the other interventions in a randomized fashion. We will also examine patient- and organization-level factors, including health inequities that influence implementation and PLWD- and care partner-reported outcomes as part of a separate implementation analysis (Aim 3). Upon successful completion, this study will provide stakeholders with the effectiveness data, as well as the implementation and PLWD-Care Partner dyad factors needed to provide this highly disseminable and implementable form of dyad-centered care with the potential to improve quality of care and quality of life, and reduce avoidable healthcare utilization in seriously ill PLWD.