Tier Palliative Care For Patients With Advanced Heart Failure or Cancer

Conditions studied

Advanced Heart Failure, Advanced Non-Colorectal Gastrointestinal Cancer, Advanced Lung Cancer, Advanced Triple Negative Breast Cancer

About this study

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.

Interventions

• Behavioral: Tier-Palliative Care — 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. TIER-PC increases the number and intensity of disciplines added to the patient's care team as their symptoms worsen and function declines.
• Behavioral: Community Health Worker — Usual Care plus the addition of a community health worker who will serve as a health coach for the participant.

Primary outcomes

• Edmonton Symptom Assessment Scale (ESAS) (12 months)
• Functional Assessment of Chronic Illness Therapy-Palliative Care Scale (FACIT-Pal) (12 months)
• Patient-reported goals of care discussion (12 months)

Eligibility information

Study locations

• Mount Sinai Queens, Astoria, New York 11102 United States
• Mount Sinai Downtown, New York, New York 10003 United States
• Mount Sinai West, New York, New York 10019 United States
• Mount Sinai Morningside, New York, New York 10025 United States
• Mount Sinai Hospital, New York, New York 10029 United States