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NCT Number: NCT06603610

Adaptation and Implementation of an Intensive Geriatric Service Worker (IGSW) Model of Care for Socially Isolated Older Adults

In this study, participants will be randomly assigned to receive either the intervention or control treatment for up to 6 months. Participants in the intervention group will receive care from an intensive geriatric service worker (IGSW), who will help the participant:

(i) Coordinate community resources and actively support participants' instrumental activities of daily living (IADLs) (e.g., linking participants with Meals-on-Wheels, taking participants to appointments) (ii) Advocate for support from home care for completing activities of daily living (ADLs) (iii) Implement patients' prioritized treatment recommendations made by healthcare professionals (e.g., supporting patients to purchase and install home safety equipment because this aligns with their values and preferences).

Participants in the control group will receive their usual care, along with a booklet containing information about locally available resources, such as those related to meal preparation, grocery delivery, housekeeping, pharmacies that deliver medicines, home care, and Wheel-Trans.

We are interested in learning about the number and demographic characteristics of participants we will be able to recruit to the study, who will remain in the study and who will be adherent to their prioritized treatment recommendations. We are also interested in learning about changes in participants' quality of life, proportion of IADLs being completed independently or with support, emergency department visit rate, and hospitalization rate at 3 and 6 months.

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Key information

Conditions

Older Adults Behavior Social Behavior Social Isolation

Age range

65 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

(i) adults aged ≥65 years old (ii) socially isolated, defined as living alone (iii) identified by the multidisciplinary Acute Care of the Elderly team, Internal Consultation Team, or Elders' Clinic as having one or more instrumental activity of daily living (IADL) impairments (defined as per the Lawton IADL scale) that could be supported by the intensive geriatric service worker (iv) capable of consenting to study participation or have a substitute decision-maker who can provide consent on their behalf (v) able to understand and communicate in English (e.g., if a participant is hearing impaired, but they can lip read or hear sufficiently with a hearing aid, they will be included) or know someone who can help with translation (vi) living in a private dwelling (e.g., apartment, house, condominium) within a geographical catchment area (i.e., boundaries will be Bloor St, Don Valley Parkway, Lakeshore Blvd, and Yonge St) (vii) a patient of a family physician or nurse practitioner (or be willing to become a patient of a family physician or nurse practitioner).

Exclusion criteria

(i) live in a retirement home, long-term care home or shelter (because there is varying availability of resources to support patients' activities of daily living (ADLs) and IADLs in these settings and we want to implement the IGSW care model where we hypothesize that it will have the greatest impact (ii) do not have a fixed address (iii) are participating in another study (iv) are being transferred to a rehabilitation facility other than Providence Healthcare prior to discharge home (Providence Healthcare is a collaborating study site; our team has an ongoing research collaboration with the medical rehabilitation unit at Providence Healthcare [where ACE and ICT medical consultation patients are transferred]

Treatment and study plan

Intensive geriatric service worker model of care

Other

Participants in the intervention group will receive care from an intensive geriatric service worker (IGSW), who will help the participant:

(i) Coordinate community resources and actively support participants' instrumental activities of daily living (IADLs) (e.g., linking participants with Meals-on-Wheels, taking participants to appointments) (ii) Advocate for support from home care for completing activities of daily living (ADLs) (iii) Implement patients' prioritized treatment recommendations made by healthcare professionals (e.g., supporting patients to purchase and install home safety equipment because this aligns with their values and preferences).

Information brochure and telephone follow-up support

Other

Participants will be e-mailed or mailed a booklet containing information about locally available resources including (1) meal preparation, (2) grocery delivery, (3) housekeeping, (4) pharmacies that deliver medications, (5) home care, and (6) Wheel-Trans. Participants will receive a scripted phone call from the study research coordinator one and three months after study enrolment to see if they have questions about the booklet material.

Primary outcomes

  1. Implementation Feasibility

    Time frame: Between 3 months to 1 year

    The number of participants (i) recruited (over the entire 12-month recruitment period and per month), (ii) retained (remain in the IGSW care model until prioritized recommendations are implemented, are discharged from the program because they are admitted to a retirement or LTC home, or complete the intervention; number of participants in the control group who provide follow-up data at 3 and 6 months) (iii) fully adherent to patients' prioritized recommendations during the trial period (% full adherence to [a] all prioritized recommendations, [b] >75% of prioritized recommendations, and [c] ≥1 prioritized recommendation at 3 and 6 months) and (iv) sustained linkages to community agencies to provide ADL and IADL support (number of participants with linkages to [a] all community agencies, [b] ≥1 community agency at 3 and 6 months).

Secondary outcomes

  1. Quality of Life

    Time frame: 3 and 6 months

    Change in quality of life will be measured with the EQ-5D-5L

  2. Proportion of IADLs being completed independently or with support

    Time frame: 3 and 6 months

  3. Emergency department visit rate

    Time frame: 3 and 6 months

  4. Hospitalization rate

    Time frame: 3 and 6 months

  5. Long-term care home admission rate

    Time frame: 3 and 6 months

  6. Length of hospitalization

    Time frame: 6 months

    This will be measured for study participants admitted to hospital.

Study contacts

Contact information is provided by the study sponsor or research team.

Jennifer Watt

CONTACT

[email protected]

1+416-864-5015

Sponsors and collaborators

Lead sponsor

Unity Health Toronto

Other

Registry information

Official study title

Adaptation and Implementation of an Intensive Geriatric Service Worker (IGSW) Model of Care for Socially Isolated Older Adults: a Pilot Randomized Trial

Important dates

Study start
2024
Primary completion
2026
Study completion
2026
First posted
Sep 19, 2024
Registry last updated
Sep 19, 2024

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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