Community-based Personalized Care and QOL

August 23, 2017 updated by: Windsor-Essex Compassionate Care Community

A Pragmatic Trial to Evaluate the Impact of Community-based Personalized Care on Quality of Life in Older and Disabled Adults

A pragmatic randomized trial to evaluate the impact of an integrated patient experience and outcome measurement system supported by citizens, caregivers and community through eHealth technology.

The primary research question is: What is the effectiveness of the WECCC approach on quality of life in people aged 65 and older or who self-identify as disabled compared to people not receiving the Health TAPESTRY program?

Study Overview

Status

Unknown

Conditions

Intervention / Treatment

Detailed Description

Secondary research questions include:

  1. what is the feasibility of obtaining study measures through routinely collected program participant data and what design adjustments are needed to balance pragmatism and high quality data collection?
  2. What are the analytic approaches to be developed to aggregate data from individual participants into meaningful units (e.g. care-team level, organizational level, social network, and geographic area) to inform ongoing adaptation of the components of the intervention?
  3. what are the perceptions of knowledge users on the usefulness of comparative effectiveness pragmatic trial evidence?

The project involves using administrative data from the ICES to create outcome measures and feedback systems for communities, and the INSPIRE PHC Unit for expertise in health system integration, care in the community, and knowledge translation.

Inclusion criteria: Seniors (65+) and people who self-identify as having a functional disability. Pilot study sites: 7 municipalities and the city of Windsor in Windsor-Essex County in Ontario. The combined total eligible population in all 8 sites is about 60,000 people, from which a minimum sample of 3000 registered patients and 1000 registered caregivers will be drawn

In Year 1, planned enrolment includes a minimum of 1100 intervention clients from all recruitment methods in the care model intervention, with similar numbers of control and intention to treat clients.

The primary outcomes are quality of life (QOL); perceived health; experience of care, and perceived social connection.

The primary outcomes for caregivers will be quality of life; perceived burden; caregiver perceptions of care; and perceived social connection.

Secondary outcomes for both will include goal attainment, distress management, symptom management, places of care, and health care utilization and costs. In terms of health equity, the investigators will measure the difference between the average/median population quality of life and cost outcomes compared to patients at the bottom income quartiles stratified by risk level. At a systems level, algorithms will be developed and applied to the data collected from participants to provide aggregate organization and system-level reports, co-designed with end users to support them as learning organizations.

Study Type

Observational

Enrollment (Anticipated)

1100

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

Study Locations

    • Ontario
      • Windsor, Ontario, Canada, N8T 1B5
        • Recruiting
        • Windsor-Essex Compassionate Care Community Program Management Office
        • Sub-Investigator:
          • Merrick Zwarenstein, PhD
        • Contact:
        • Contact:
        • Principal Investigator:
          • Michelle Howard, PhD
        • Sub-Investigator:
          • Lisa Dolovich, PhD
        • Sub-Investigator:
          • Kathryn Pfaff, PhD

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

65 years and older (Older Adult)

Accepts Healthy Volunteers

Yes

Genders Eligible for Study

All

Sampling Method

Probability Sample

Study Population

Seniors who identify with having a functional disability or serious chronic disease; and informal caregivers. Many patients within this broad target population will be at risk of worsening quality of life or escalating health care utilization now or in the future due to aging, disease progression, or unmet health, social or economic needs.

Description

Inclusion Criteria:

Individuals who:

  1. are 65 years of age and over
  2. have a long-term disability or one or more chronic diseases
  3. able to communicate in English OR can provide a formal or informal translator willing to facilitate the participant's involvement

Exclusion Criteria:

Individuals not meeting above criteria

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

Cohorts and Interventions

Group / Cohort
Intervention / Treatment
WE Health Tapestry
Completion of baseline measures then enrolled in a community-based personalized care intervention that consists of four core elements: volunteer support, interprofessional care, technology, social network linkage
volunteer support, health technology, interprofessional care, social network linkage
Usual Care
Completion of baseline measures with six-month delayed community-based personalized care intervention: volunteer support, interprofessional care, technology, social network linkage
volunteer support, health technology, interprofessional care, social network linkage

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Quality of Life
Time Frame: Baseline and then monthly for 24 months
McGill QoL - patient and family
Baseline and then monthly for 24 months
Perceived health
Time Frame: Baseline and then monthly for 24 months
EQ-5D-5L - patient
Baseline and then monthly for 24 months

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Caregiver Burden 1
Time Frame: Baseline and then monthly for 24 months
InterRAI-home care
Baseline and then monthly for 24 months
Caregiver Burden 2
Time Frame: Baseline and then monthly for 24 months
Zarit burden interview
Baseline and then monthly for 24 months
Patient experience
Time Frame: Baseline and then monthly for 24 months
CANHelp Patient
Baseline and then monthly for 24 months
Family experience
Time Frame: Baseline and then monthly for 24 months
CANHelp Family
Baseline and then monthly for 24 months
Symptom management 1
Time Frame: Baseline and then monthly for 24 months
Edmonton Symptom Assessment Scale
Baseline and then monthly for 24 months
Symptom management 2
Time Frame: Baseline and then monthly for 24 months
Palliative Performance Scale
Baseline and then monthly for 24 months
Symptom management 3
Time Frame: Baseline and then monthly for 24 months
InterRAI-home care
Baseline and then monthly for 24 months
Health services utilization 1
Time Frame: Baseline and then monthly for 24 months
hospitalization
Baseline and then monthly for 24 months
Health services utilization 2
Time Frame: Baseline and then monthly for 24 months
Emergency care
Baseline and then monthly for 24 months

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Collaborators

Investigators

  • Principal Investigator: Michelle Howard, PhD, McMaster University
  • Principal Investigator: Kathryn Pfaff, PhD, University of Windsor
  • Principal Investigator: Lisa Dolovich, PhD, McMaster University

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

July 1, 2017

Primary Completion (Anticipated)

September 30, 2018

Study Completion (Anticipated)

September 30, 2018

Study Registration Dates

First Submitted

August 21, 2017

First Submitted That Met QC Criteria

August 23, 2017

First Posted (Actual)

August 28, 2017

Study Record Updates

Last Update Posted (Actual)

August 28, 2017

Last Update Submitted That Met QC Criteria

August 23, 2017

Last Verified

August 1, 2017

More Information

Terms related to this study

Other Study ID Numbers

  • HealthTap-WEPilot

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

UNDECIDED

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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