Palliative Care for Patients With Dementia

The objective of this randomized controlled trial is to study the impact of a new home based palliative care program on patients' symptoms, quality of life, satisfaction with care, completion of advance care planning documentation and receipt of care consistent with preferences. In addition, the study will examine the impact of this model of care on patient healthcare utilization, including hospitalization, emergency department utilization, and hospice use prior to death. The trial will also include patients' caregivers, in order to examine the impact of the intervention on caregiver burden and prevalence of depression.

Patients randomized to the intervention will be scheduled for an intake visit. This visit will be undertaken by the team's registered nurse and/or social worker, together with a community health worker, and other team members (advanced practice nurse, MD), depending on patients' needs. Visits will combine a combination of video-teleconferencing technology and in person visits. Following this visit, and in conjunction with the nurse practitioner and/or MD, a care plan will be developed to address areas of clinical need highlighted during the intake visit.

Patients in the intervention arm will receive ongoing monitoring and input (telephone-based, video-based, and in-person) from members of the clinical team, dependent on their identified needs. Patients' cases will be discussed at the weekly IDT meeting, as appropriate to the level of clinical need. Patients and caregivers will be provided with access to a 24 hour telephone line, staffed by a Mount Sinai based physician, which acts as an advice line out of hours. These physicians will be able to provide advice to patients and caregivers.

Inclusion criteria

• have advanced dementia, based on Global Deterioration Score (GDS)>6
• impairment in at least one activity of daily living (ADL -which is inherent in this level of GDS)
• at least one hospitalization or ED visit within the last 12 months
• a physician who is primarily responsible for their dementia-related care whose clinical outpatient site is associated with one of the four Mount Sinai sites in Manhattan
• a family caregiver willing to enroll
• a residence in Manhattan where they are currently living (not in a long-term care facility)
• capacity to consent or a legal representative available to provide consent
• fluency in English or Spanish, or their legal representative must be fluent in English or Spanish
• age >64.

Exclusion criteria

• Does not have a family caregiver to enroll
• Does not reside in Manhattan outside of long-term care facility
• Does not have fluency in English or Spanish Doesn't