Palliative Care, Advance Care Planning, Skilled Nursing Facilities
Conditions
Keywords
Palliative Care Consultation, Medicare, Skilled Nursing
Brief summary
Close to one-third of Medicare decedents use the Medicare skilled nursing facility (SNF) benefit in the 6 months prior to death. SNF care often increases the risk for more aggressive, potentially burdensome treatments and unrecognized or undertreated symptoms. Palliative care is goal-directed, patient and family-centered care that focuses on a wide range of physical, psychosocial, and spiritual needs for persons with serious, life-limiting illnesses. Effective palliative care relieves suffering, enhances communication, and improves end-of-life care and decision making for seriously ill older adults. Despite its association with improved quality of care, higher satisfaction, and better symptom management at the end of life, palliative care is not widely available to Medicare patients in the Skilled Nursing Facility (SNF) setting. Palliative care consultation (PCC) is one approach that can potentially improve care for older adults with advanced illness in SNFs. This pilot study will test an evidence-based palliative care consult intervention for older adult SNF patients in nursing homes by comparing the patient/family caregiver reported quality of life in two participant groups: one receiving a PCC and the other receiving standard care.
Interventions
Trained provider will discuss illness trajectories, establish and communicate patient-directed goals that guide health care decisions, identify and treat illness-related symptoms, and identify psycho-spiritual needs and approaches to mitigate suffering.
Sponsors
University of Maryland, Baltimore
Study design
Allocation
NON_RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE
Masking
NONE
Intervention model description
Pre-post design where control data will be collected prior to intervention being implemented
Eligibility
Sex/Gender
ALL
Age
60 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Admitted to a participating nursing home under the Medicare SNF benefit * English speaking * If non-verbal or unable to participate in a conversation, a legally authorized representative(LAR) or surrogate decision maker who can participate in the study * A diagnosis of one or more advanced serious illness using established criteria * One global indicator for a PCC at SNF admission (i.e., primary provider would not be surprised if patient died in 12 months; frequent hospital or SNF admissions; complex care requirements; decline in function; feeding intolerance; or unintended decline in weight)
Exclusion criteria
* Patients who have previously received or are referred for a SNF-based PCC by their primary care team
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Number of Participants Who Completed Patient Quality of Life Surveys | Collected upon admission to the nursing home and enrollment and again 15-21 days after enrollment in the study (control group) or intervention received (intervention group). | The Patient Outcome Survey (POS) 10 item Survey that measures quality of life in five dimensions: 1) physical; 2) emotional; 3) psychological; 4) spiritual needs, and 5) provision of information and support. Items scored on a 5 point Likert Scale (0=not at all, 4= overwhelmingly) based on symptom/need in the past week. Overall profile score is calculated by summing responses (range 0-40). Higher values represent a worse outcome. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Number of Participants Who Completed the Consult Satisfaction Survey (CSQ) | Collected within 15-21days of palliative care consultation for the intervention group. | Measured using the Consultation Satisfaction Questionnaire (CSQ). The CSQ is an 18 item patient/caregiver-reported instrument that measures communication and satisfaction of a consult in four domains: 1) general satisfaction, 2) professional care, 3) depth of relationship, 4) perceived length of consultation.(scale format: 5-point Likert Scale (0= strongly disagree, 4=strongly agree).Overall score is calculated by summing responses (range 0-72). Higher values represent a worse outcome. |
| Adherence to SNF-PCC Recommendations | 30 Days post-admission | Adherence Protocol. Medical record review and/or phone interview with patient/caregiver We will determine a recommendation adherence score after each participants' SNF-PCC. Each recommendation will be assigned 2 points, then we will define full (2 points), partial (1 point) and no adherence (0 point) to each recommendation. We will sum the points for each SNF-PCC recommendation and use this as the denominator. We will sum each recommendation with full, partial, no adherence and use this as the numerator. The fraction will be converted to a percentage ranging from 0-100% reflecting the recommendation adherence score. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Standard Care Participants received the standard Medicare Skilled Nursing Facility care. | 10 |
| Palliative Care Consult Participants received the standard Medicare Skilled Nursing Facility care plus a Palliative Care Consultation with a trained provider.
Palliative Care Consultation: Trained provider discussed illness trajectories, establish and communicate patient-directed goals that guide health care decisions, identify and treat illness-related symptoms, and identify psycho-spiritual needs and approaches to mitigate suffering. | 35 |
| Total | 45 |
Baseline characteristics
| Characteristic | Standard Care | Palliative Care Consult | Total |
|---|---|---|---|
| Age, Categorical <=18 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical >=65 years | 10 Participants | 35 Participants | 45 Participants |
| Age, Categorical Between 18 and 65 years | 0 Participants | 0 Participants | 0 Participants |
| Ethnicity (NIH/OMB) Hispanic or Latino | 0 Participants | 0 Participants | 0 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 10 Participants | 35 Participants | 45 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 0 Participants | 1 Participants | 1 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) White | 10 Participants | 34 Participants | 44 Participants |
| Region of Enrollment United States | 10 participants | 35 participants | 45 participants |
| Sex: Female, Male Female | 7 Participants | 27 Participants | 34 Participants |
| Sex: Female, Male Male | 3 Participants | 8 Participants | 11 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 10 | 0 / 35 |
| other Total, other adverse events | 0 / 10 | 0 / 35 |
| serious Total, serious adverse events | 0 / 10 | 0 / 35 |
Outcome results
Primary
Number of Participants Who Completed Patient Quality of Life Surveys
The Patient Outcome Survey (POS) 10 item Survey that measures quality of life in five dimensions: 1) physical; 2) emotional; 3) psychological; 4) spiritual needs, and 5) provision of information and support. Items scored on a 5 point Likert Scale (0=not at all, 4= overwhelmingly) based on symptom/need in the past week. Overall profile score is calculated by summing responses (range 0-40). Higher values represent a worse outcome.
Time frame: Collected upon admission to the nursing home and enrollment and again 15-21 days after enrollment in the study (control group) or intervention received (intervention group).
Population: Both intervention and control groups are administered a baseline POS and follow up POS.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Standard Care (Control Group) | Number of Participants Who Completed Patient Quality of Life Surveys | Completed Baseline POS | 10 participants |
| Standard Care (Control Group) | Number of Participants Who Completed Patient Quality of Life Surveys | Completed Follow up POS | 10 participants |
| Palliative Care Consult (Intervention Group) | Number of Participants Who Completed Patient Quality of Life Surveys | Completed Baseline POS | 35 participants |
| Palliative Care Consult (Intervention Group) | Number of Participants Who Completed Patient Quality of Life Surveys | Completed Follow up POS | 35 participants |
Secondary
Adherence to SNF-PCC Recommendations
Adherence Protocol. Medical record review and/or phone interview with patient/caregiver We will determine a recommendation adherence score after each participants' SNF-PCC. Each recommendation will be assigned 2 points, then we will define full (2 points), partial (1 point) and no adherence (0 point) to each recommendation. We will sum the points for each SNF-PCC recommendation and use this as the denominator. We will sum each recommendation with full, partial, no adherence and use this as the numerator. The fraction will be converted to a percentage ranging from 0-100% reflecting the recommendation adherence score.
Time frame: 30 Days post-admission
Population: Data were not collected due to study teams limited access to the medical records to review Adherence to SNF-PCC recommendations (due to Covid 19)
Secondary
Number of Participants Who Completed the Consult Satisfaction Survey (CSQ)
Measured using the Consultation Satisfaction Questionnaire (CSQ). The CSQ is an 18 item patient/caregiver-reported instrument that measures communication and satisfaction of a consult in four domains: 1) general satisfaction, 2) professional care, 3) depth of relationship, 4) perceived length of consultation.(scale format: 5-point Likert Scale (0= strongly disagree, 4=strongly agree).Overall score is calculated by summing responses (range 0-72). Higher values represent a worse outcome.
Time frame: Collected within 15-21days of palliative care consultation for the intervention group.
Population: Participants in the Control arm were not administered the CSQ survey. Only participants in the intervention group were administered the CSQ survey
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Palliative Care Consult (Intervention Group) | Number of Participants Who Completed the Consult Satisfaction Survey (CSQ) | 10 participants |