Designing Care Management for Hospice Transitions for Persons Living With Advanced Dementia

Summary

This study will test a care management intervention to guide end-of-life care and hospice transitions for persons with dementia and their care partners receiving home healthcare and ascertain feasibility, acceptability, fidelity, and usability of a dementia care management hospice transitions checklist. This study will also examine hospice enrollment, time to enrollment, and care partner satisfaction with the intervention. The intervention will be delivered within usual care management within a large home healthcare agency.

Interventions

• Dementia Care Management Checklist for Hospice Transitions · BEHAVIORAL

  Intervention: After appropriate care partners of hospice-eligible PLWD are identified who will be receiving the checklist intervention, care managers will perform telephonic outreach to engage them in a conversation about care needs (as they would in typical clinical practice). The telephonic outreach will be followed up with a recommendation for follow up by a medical provider who may conduct a hospice care assessment and engage the care partner in decision-making surrounding the hospice referral and enrollment process. This intervention was co-designed with care partners, home healthcare professionals, administrators, and medical providers. It is meant to be comprehensive and speak to the needs of all relevant parties engaged in the care of persons with dementia. It is developed so that it can be scaled and implemented widely.

Published eligibility criteria

Verbatim from the registry. Only the site can decide how these apply to a specific patient.

Inclusion:

Care Partners and PLWD Dyad:

1. Care partners of PLWD who have a diagnosis of moderate to severe dementia.
2. Able to provide informed consent

HHC Professionals:

Care Managers and Field Nurses:

1. Care managers who regularly engage hospice transitions with care partners of PLWD
2. Age 18 or older

Medical Providers:

1. Medical providers (e.g., physicians and nurse practitioners) who refer patients for hospice enrollment.
2. Age 18 or older

HHC Administrators:

1. Home healthcare administrators who work with the Certified Home Health Agency or the Advanced Illness Management Program that refers patients to hospice care
2. Age 18 or older

Exclusion

Care Partner and PLWD Dyad

1. Under age 18
2. Care partners who are caring for PLWD with Mild Cognitive Impairment
3. PLWD with Mild Cognitive Impairment

HHC Professionals: Care Managers, Medical Providers, Administrators

1\. Do not have experience managing hospice transitions for PLWD

Sites (1)

• NYU Rory Meyers College of Nursing and VNS Health, New York, New York · Recruiting