Care Transitions Program for Dementia

Overseen by Patrick M Archambault, MD, MSc, FRCPC

Age: 65+

Sex: Any

Travel: May Be Covered

Time Reimbursement: Varies

Trial Phase: Academic

Recruiting

Sponsor: Laval University

Disqualifiers: Under 65, Long-term care, others

No Placebo Group

Approved in 1 Jurisdiction

Trial Summary

What is the purpose of this trial?

The prevalence of major neurocognitive disorders (MNCDs), particularly Alzheimer's disease, among older adults is increasing. These individuals and their caregivers often face challenges due to inefficient and poorly coordinated care transitions, negatively impacting patients, caregivers, healthcare professionals, and the healthcare system itself. To address this, the Quebec Ministry of Health and Social Services has released Phase 3 of its Ministerial Guidance on Major Neurocognitive Disorders, aiming to enhance care coordination between primary healthcare professionals and those living with MNCDs and their caregivers. Quebec's healthcare system comprises various organizations providing care and services to individuals with MNCDs. Each organization faces unique challenges hindering improvement initiatives. However, common obstacles persist: inadequate communication systems for sharing vital information, lack of access to data for measuring care transition quality, and the absence of patient/caregiver satisfaction assessments to inform service enhancements. Additionally, organizations require support in managing change. This need for improvement, coupled with the aspiration for a patient-centered learning health system (LHS), motivated the Institut national d'excellence en santé et services sociaux (INESSS), the Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS CA), and the research team to collaborate on adapting a proven continuous improvement program: the CoMPAS+ MNCD Program. The Program will involve reflecting on best practices and identifying local challenges within participating Family Medicine Groups (FMGs) to propose and implement solutions. The CONSTELLATIONS Living Lab project has been tasked with co-developing, implementing, and evaluating the Program's impact on care transitions over two years. These findings will inform decision-makers and stakeholders about the Program's adaptability to the Chaudière-Appalaches region, guiding local and provincial decision-makers on healthcare system improvements and emphasizing the importance of supporting an LHS.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications. It's best to discuss this with the research team or your doctor.

What data supports the effectiveness of the Care Transitions Program for Dementia treatment?

Research shows that care coordination programs for dementia, like the MIND at Home Trial, can help reduce the use of health services, which suggests they may improve care transitions and support for patients and caregivers. ^{1 2 3 4 5}

Is the Care Transitions Program for Dementia safe for humans?

The available research does not provide specific safety data for the Care Transitions Program for Dementia or its related programs. However, non-drug approaches for dementia care, like community care coordination, have been studied and generally focus on improving care without known safety concerns. ^{6 7 8 9 10}

What makes the CoMPAS+ MNCDs Program unique compared to other treatments for dementia?

The CoMPAS+ MNCDs Program is unique because it focuses on improving care transitions for people with dementia by training healthcare professionals, enhancing communication strategies, and designating a care navigator to support patients from the time of diagnosis. This approach aims to ensure smoother transitions between different care settings, which is not typically the focus of standard dementia treatments. ^{11 12 13 14 15}

Research Team

Patrick M Archambault, MD, MSc, FRCPC

Principal Investigator

Laval University

Eligibility Criteria

This trial is for older adults with major neurocognitive disorders like Alzheimer's, and their caregivers. It focuses on improving care transitions between healthcare providers to enhance coordination and support.

Inclusion Criteria

Consent to the research team collecting data from the medical records of the person being cared for (FMG Electronic Medical Record (EMR) when accessible, Hospital Electronic Patient Record (EPR) when accessible, etc.)

Be a participant in the CoMPAS+ MNCD workshops and be part of at least one of the following categories of participants: Health professionals working in a CISSS CA health facility or with a community organization, CISSS CA decision-makers or local managers, Community service representative (e.g., Alzheimer's Society, L'APPUI)

Be able to consent independently to research and reside at home, in a retirement home, in an intermediate residence, or a family-type resource

Exclusion Criteria

I do not agree to share my medical records for this trial.

User living in a provincial long-term care facility at the time of recruitment

I am over 65, have a significant memory or thinking problem, and cannot consent to research on my own without a caregiver.

Trial Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Implementation

Implementation of the CoMPAS+ MNCD Program through workshops and interventions in Local Services Networks

12-15 months

Multiple workshops and interventions

Follow-up

Participants are monitored for the impact of the Program on care transitions, quality of life, and caregiver burden

15 months

Telephone questionnaires at multiple time points

Evaluation

Evaluation of the Program's sustainability and scale-up potential through focus groups and interviews

12-15 months

Treatment Details

Interventions

• CoMPAS+ MNCDs Program (Behavioural Intervention)

Trial Overview The CoMPAS+ MNCDs Program is being tested, which aims to improve the quality of care transitions for patients with neurocognitive disorders through better practices and local solutions in Family Medicine Groups.

Participant Groups

Group I: Local Services Network (LSN) Montmagny-L Islet Experimental Treatment 1 Intervention

The local services network (LSN) Montmagny-L'Islet is set in a semi-urban region with a small community hospital. The CoMPAS+ TNCM workshops (intervention) in the LSN Montmagny-L'Islet will be conducted with health professionals and careviver partners from the FMG of Montmagny (GMF de Montmagny) which comprises the organisational merging of 5 different medical clinics in the region. Will also participate in the workshops are healthcare professionals from the home care services team, and from the emergency department of the Hopital de Montmagny. The population that will be recruited to evaluate the impact of the intervention will have either 1) received home care services within the last 6 months before the intervention; 2) visited the emergency department of Hopital de Montmagny within the last 6 months before the intervention; or 3) consulted with their family doctor within the last 6 months before the intervention.

Group II: Local Services Network (LSN) Bellechasse Experimental Treatment 1 Intervention

The local services network (LSN) of Bellechasse is set in a rural area. The population requiring urgent medical care are lead to Hotel-Dieu de Lévis (45 km, Alphonse-Desjardins) or Hopital de Montgagny (30 km, Montmagny-L'Islet). The CoMPAS+ TNCM workshops (intervention) in the LSN of Bellechasse will be conducted with health professionals and caregiver partners from the FMG Rive de l'Etchemin (GMF Rive de l'Etchemin) which comprises the organisational merging of 2 medical clinics. Will also participate in the workshops members the home care team. The population that will be recruited to evaluate the impact of the intervention will have either 1) received home care services within the last 6 months before the intervention; 2) visited one of the 2 emergency departments (Hotel-Dieu de Lévis or Hopital de Montmagny) within the last 6 months before the intervention; or 3) consulted with their primary care team within the last 6 months before the intervention.

Group III: Local Services Network (LSN) Alphonse-Desjardins Experimental Treatment 1 Intervention

The local services network (LSN) Alphonse-Desjardins is set in a urban region with the most important community hospital of the greater region of Chaudière-Appalaches. The CoMPAS+ TNCM workshops (intervention) in the LSN Alphonse-Desjardins will be conducted with health professionals and caregiver partners from the FMG of Lévis (GMF-U de Lévis), the home support services team, and the emergency department of the Hotel-Dieu de Lévis. The population that will be recruited to evaluate the impact of the intervention will have either 1) received home care services within the last 6 months before the intervention; 2) visited the emergency department of Hotel-Dieu de Lévis within the last 6 months before the intervention; or 3) consulted with their primary health care team within the last 6 months before the intervention.

Who Is Running the Clinical Trial?

Laval University

Lead Sponsor

Trials

439

Recruited

178,000+

Institut national d'excellence en santé et service sociaux

Collaborator

Trials

1

Recruited

700+

CISSS de Chaudière-Appalaches

Collaborator

Trials

9

Recruited

16,500+

Findings from Research

The novel dementia care coordination program did not significantly reduce the use of acute care or inpatient services, but it did lead to an increase in outpatient dementia and mental health visits over 18 months, indicating improved access to specialized care.

Participants in the intervention group significantly increased their use of home and community-based support services, suggesting that the program may help individuals with dementia remain in their homes longer and receive necessary support.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Health Services Utilization in Older Adults with Dementia Receiving Care Coordination: The MIND at Home Trial. Amjad, H., Wong, SK., Roth, DL., et al.[2019]

The Systematic Care Program for Dementia (SCPD) did not significantly reduce the rate of institutionalization for dementia patients after 12 months, despite being implemented across six community mental health services with 295 patient-caregiver dyads.

Key predictors of institutionalization included the caregiver's sense of competence and depressive symptoms, as well as the patient's behavioral issues and severity of dementia, highlighting the importance of caregiver support in managing dementia.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Systematic care for caregivers of patients with dementia: a multicenter, cluster-randomized, controlled trial. Spijker, A., Wollersheim, H., Teerenstra, S., et al.[2017]

An integrative review identified 71 reports on measures of care transitions and coordination for individuals living with dementia, highlighting the need for better evaluation of these measures in terms of person- and family-centered care.

While some measures were effective in assessing outcomes like healthcare use and costs, there was significant variability in definitions and time requirements for data collection, indicating a need for improved and standardized measures in future research.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

An integrative review of measures of transitions and care coordination for persons living with dementia and their caregivers. Hirschman, KB., McHugh, M., Morgan, B.[2023]

In a study of 16,186 older adults with dementia, 21.3% experienced frequent transitions in care, highlighting the instability in their living situations, with many moving between home, hospitals, and nursing facilities.

Among those with moderate to severe dementia, a significant number transitioned back home after hospital stays, indicating that even severely impaired individuals frequently change care settings, which can complicate their management and support.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Transitions in Care in a Nationally Representative Sample of Older Americans with Dementia. Callahan, CM., Tu, W., Unroe, KT., et al.[2022]

In a study of 31,648 community-dwelling older veterans with dementia, a higher continuity of care (COC) score was associated with a 4.6% increased likelihood of successful direct discharge to the community after hospitalization.

However, the impact of COC was not significant for discharges through post-acute care facilities, suggesting that while better continuity may help some patients, its overall effect is small and requires further investigation.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Continuity of Care and Successful Hospital Discharge of Older Veterans With Dementia. Lei, L., Cai, S., Conwell, Y., et al.[2022]

A study analyzing discharge documentation for 60 older adults with dementia revealed that only 17% of the documentation met excellent standards for transitional care needs, indicating significant gaps in the quality of information provided during care transitions.

The variability in discharge documentation quality (37% excellent, 43% adequate, and 20% poor) highlights the urgent need for improvements to ensure safe and effective care for individuals with dementia moving from hospital to nursing home settings.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Analysis of discharge documentation for older adults living with dementia: A cohort study. Parker, KJ., Phillips, JL., Luckett, T., et al.[2021]

Community care coordination has shown promise in reducing the rate of nursing home admissions for older people with dementia, with a significant risk ratio of 0.66 based on data from 303 participants across two studies.

Other non-pharmacological interventions, such as psychoeducation and multifactorial approaches, did not demonstrate a significant effect on preventing hospital or nursing home admissions, suggesting that not all interventions are equally effective.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Non-pharmacological interventions to prevent hospital or nursing home admissions among community-dwelling older people with dementia: A systematic review and meta-analysis. Lee, DA., Tirlea, L., Haines, TP.[2021]

The National Institute on Aging IMPACT Collaboratory aims to enhance the integration of evidence-based care for over 5 million persons living with dementia and their caregivers by funding up to 40 pilot embedded pragmatic clinical trials (ePCTs) focused on nonpharmacologic interventions.

Initial findings from the pilot core revealed that many investigators are unfamiliar with ePCTs and that proposed studies often lack essential design elements, leading to the establishment of three key criteria for future pilot studies to ensure their viability.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Building a National Program for Pilot Studies of Embedded Pragmatic Clinical Trials in Dementia Care. Brody, AA., Barnes, DE., Chodosh, J., et al.[2021]

Embedded pragmatic clinical trials (ePCTs) can effectively utilize existing healthcare data, such as Medicare claims and electronic health records, to improve research on Alzheimer's disease and related dementias, which often involve complex care settings.

These ePCTs are particularly valuable for people living with dementia, as they allow for better case identification and integration of diverse care environments, enhancing the relevance and applicability of research findings in real-world scenarios.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Using Healthcare Data in Embedded Pragmatic Clinical Trials among People Living with Dementia and Their Caregivers: State of the Art. Bynum, JPW., Dorr, DA., Lima, J., et al.[2021]

The Dementia Cal MediConnect project, a 5-year initiative involving local Alzheimer's organizations and 10 managed care health plans in California, successfully implemented systems changes to improve dementia care, including better detection, diagnosis, and support for caregivers.

The advocacy model used in this project demonstrated that targeted efforts can enhance dementia-capable practices within healthcare systems, suggesting that similar approaches could be beneficial in other regions to better serve people living with dementia.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Building an advocacy model to improve the dementia-capability of health plans in California. Hollister, BA., Yeh, J., Ross, L., et al.[2021]

The Laval-ROSA Transilab aims to enhance care for people living with dementia by improving transitions between different healthcare settings through targeted innovations, including training for primary care professionals and an early referral process to community services.

The project employs a multi-methods living lab approach, involving co-development and co-evaluation of strategies to ensure sustainable improvements in dementia care, ultimately benefiting patients, caregivers, and healthcare providers.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Research protocol of the Laval-ROSA Transilab: a living lab on transitions for people living with dementia. Dufour, I., Arsenault-Lapierre, G., Guillette, M., et al.[2023]

Older adults with dementia experience significantly higher rates of nursing facility use, hospitalizations, and transitions in care compared to those without a dementia diagnosis, indicating a complex care trajectory.

Most transitions to nursing facilities for individuals with dementia occur after hospitalizations, highlighting the interconnectedness of care settings and the need for coordinated support during these transitions.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Transitions in care for older adults with and without dementia. Callahan, CM., Arling, G., Tu, W., et al.[2022]

The ADMIT Me tool was developed to improve safe transitions of care for individuals with Alzheimer's and dementia, based on feedback from focus groups involving caregivers, emergency department nurses, and first responders.

Participants in the focus groups unanimously agreed that the ADMIT Me tool would enhance safety during care transitions by promoting clear communication and collaboration among healthcare providers, ultimately leading to more patient-centered care.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Enhancing the ADMIT Me Tool for Care Transitions for Individuals With Alzheimer's Disease. Moore, JR., Sullivan, MM.[2018]

Individuals newly diagnosed with dementia experience a significant increase in care transitions, particularly hospitalizations, during the year of diagnosis, indicating a critical period for intervention.

Receiving recommended dementia care and high-quality primary care is linked to fewer transitions across care settings, suggesting that improved care can help manage the complexities faced by dementia patients.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Diagnosis and Disruption: Population-Level Analysis Identifying Points of Care at Which Transitions Are Highest for People with Dementia and Factors That Contribute to Them. Sivananthan, SN., McGrail, KM.[2022]

References

1. United States pubmed.ncbi.nlm.nih.gov

Health Services Utilization in Older Adults with Dementia Receiving Care Coordination: The MIND at Home Trial. [2019]

2. England pubmed.ncbi.nlm.nih.gov

Systematic care for caregivers of patients with dementia: a multicenter, cluster-randomized, controlled trial. [2017]

3. United States pubmed.ncbi.nlm.nih.gov

An integrative review of measures of transitions and care coordination for persons living with dementia and their caregivers. [2023]

4. United States pubmed.ncbi.nlm.nih.gov

Transitions in Care in a Nationally Representative Sample of Older Americans with Dementia. [2022]

5. United States pubmed.ncbi.nlm.nih.gov

Continuity of Care and Successful Hospital Discharge of Older Veterans With Dementia. [2022]

6. England pubmed.ncbi.nlm.nih.gov

Analysis of discharge documentation for older adults living with dementia: A cohort study. [2021]

7. England pubmed.ncbi.nlm.nih.gov

Non-pharmacological interventions to prevent hospital or nursing home admissions among community-dwelling older people with dementia: A systematic review and meta-analysis. [2021]

8. United States pubmed.ncbi.nlm.nih.gov

Building a National Program for Pilot Studies of Embedded Pragmatic Clinical Trials in Dementia Care. [2021]

9. United States pubmed.ncbi.nlm.nih.gov

Using Healthcare Data in Embedded Pragmatic Clinical Trials among People Living with Dementia and Their Caregivers: State of the Art. [2021]

10. United States pubmed.ncbi.nlm.nih.gov

Building an advocacy model to improve the dementia-capability of health plans in California. [2021]

11. England pubmed.ncbi.nlm.nih.gov

Research protocol of the Laval-ROSA Transilab: a living lab on transitions for people living with dementia. [2023]

12. United States pubmed.ncbi.nlm.nih.gov

Transitions in care for older adults with and without dementia. [2022]

13. United States pubmed.ncbi.nlm.nih.gov

Improving transitions between acute mental health and residential care. [2019]

14. United States pubmed.ncbi.nlm.nih.gov

Enhancing the ADMIT Me Tool for Care Transitions for Individuals With Alzheimer's Disease. [2018]

15. United States pubmed.ncbi.nlm.nih.gov

Diagnosis and Disruption: Population-Level Analysis Identifying Points of Care at Which Transitions Are Highest for People with Dementia and Factors That Contribute to Them. [2022]