Tier - Palliative Care for Patients with Advanced Heart Failure or Cancer (TIER-PC)

Mount Sinai Health System

Status: Enrolling

Conditions: Advanced Non-colorectal Gastro-intestinal Cancer; Advanced Lung Cancer; Advanced Heart Failure

Treatments: Behavioral: Tier - Palliative Care

Study type: Interventional

Funder types: Other; NIH

Identifiers

NCT06228209

1R56NR020624-01 (U.S. NIH Grant/Contract)

STUDY-22-00591

Details and patient eligibility

About

TIER-PC is an adaptive model of delivering palliative care that provides the right level of care to the right patients at the right time. It represents an adaption of the Mount Sinai PALLIATIVE CARE AT HOME (PC@H) program, which delivers home-based palliative care. TIER-PC increases the number and intensity of disciplines added to the patient's care team as their symptoms worsen and function declines. In Tier 1, patients who are able to care for themselves and no/mild symptoms receive a community health worker (CHW) trained to elicit illness understanding in a culturally competent way. In Tier 2, for patients with poorer function and mild symptoms, a social worker (SW), trained in serious illness communication, joins the CHW to further elicit patients' goals and prognostic understanding while communicating symptom needs to their primary clinician. In Tier 3, as function decreases and symptoms increase, an advance practice nurse (APN) joins the CHW and SW to manage complex symptoms. Finally, in Tier 4, for those older adults with the poorest function and most complex symptoms, a physician joins the team to ensure that the most complex needs (e.g., end-of-life treatment preferences and multifaceted symptom control) are met. The CHW follows patients longitudinally across all tiers and re-allocates them to the appropriate tier based on their evolving needs.

Full description

The study aims are:

• To evaluate the feasibility of enrolling patients into a study of TIER-PC; and
• To provide data on subject retention, randomization success, intervention fidelity and estimates of the efficacy of the TIER-PC intervention in improving patients' symptoms and quality of life, and reducing emergency department visits and hospitalizations.

This study will enroll 60 subjects with advanced non-colorectal gastrointestinal or lung cancer or advanced HF, 30 of which will be randomized to receive the study intervention and 30 of which will be randomized to receive usual care.

The expected study duration is 18 months from enrollment initiation to completion of data analysis consisting of a 52- week active enrollment period, a 3 month follow up period, and a three month data analysis period.

Enrollment: 28 estimated patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• Advanced Heart Failure (HF) with two HF-related hospitalizations within the last 12 months or
• Advanced lung or non-colorectal gastrointestinal cancer (pancreatic, gastric, hepatobiliary, small bowel, esophageal) with one hospitalization within the last 6 months
• KPS > 50% (ECOG 0, 1 or 2)
• > 2 outpatient MSHS visits in prior 12 months
• Manhattan residence
• Capacity to provide informed consent
• English or Spanish fluency
• > 18 years of age

Exclusion criteria

• Diagnoses of both cancer and advanced HF
• Lung cancer with a driver mutation (e.g., EGFR) that confers a favorable prognosis and does not follow typical trajectory
• Patients with > 1 visit to Outpatient Supportive Oncology/Cardiology visit
• Patients with last visit to Outpatient Supportive Oncology/Cardiology < 3 months ago
• Previous receipt of a ventricular assist device or previous heart transplantation
• Receiving hospice care prior to study enrollment or enrolled in another study of a palliative care patient/caregiver intervention
• Living in a facility (subacute rehab, long-term care facility, hospice facility or residence)
• Callahan 6-Item Cognitive Screening score ≤3

Trial design

Primary purpose: Health Services Research

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

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28 participants in 2 patient groups

Tier - Palliative Care

Experimental group

Description:

Patients/caregivers will be cared for by an interdisciplinary team that includes a social worker, nurse, community health worker, nurse practitioner, and physician.

Treatment:

Behavioral: Tier - Palliative Care

Usual care

No Intervention group

Description:

Patients will be cared for by the physician who treats their serious illness (cardiologist, oncologist, primary treating clinician) and other illnesses.