NCT05651308

Improving How People Living With Dementia Are Selected for Care Coordination

Improving How People Living With Dementia Are Selected for Care Coordination: A Pragmatic Clinical Trial Embedded in an Accountable Care Organization

• Status: Completed
• Phase: N/A
• Study type: Interventional
• Enrollment: 385 (actual)
• Sponsor: Weill Medical College of Cornell University · Academic / Other
• Sex: All
• Age: 65 Years
• Healthy volunteers: Not accepted

Summary

Many people living with dementia (PLWD) and their care partners may benefit from the assistance of a care coordinator, a member of the medical team who facilitates communication among all the people involved. However, care coordinators' time is limited, and there is uncertainty about which patients should be selected to receive their help. This pragmatic clinical trial embedded in an accountable care organization will determine the comparative effectiveness of two approaches for assigning care coordinators to PLWD.

Detailed description

This project will use a pragmatic clinical trial embedded in an accountable care organization (ACO) to determine the comparative effectiveness of two different approaches for selecting PLWD to receive support from care coordinators: (1) an approach that assigns PLWD to care coordinators based on care partners' self-reported difficulty with care coordination, or (2) usual care, which generally assigns PLWD to care coordinators after hospital discharge, regardless of perceived need. The investigators will include community-dwelling Medicare beneficiaries ≥65 years old with dementia who have been attributed to the NewYork Quality Care ACO and who have fragmented care. The investigators will randomize the participants into two groups. This study is highly pragmatic, and the intervention is sustainable and scalable. Moreover, the proposed approach has the potential to improve care delivery and outcomes for PLWD.

Conditions

• Dementia

Interventions

Type	Name	Description
BEHAVIORAL	Care coordination delivered based on perceived need	If proxies for patients in intervention group report on the survey that they experience difficulty coordinating care among the patients' providers, the patient will be selected for care management services. Those services will attempt to address the problems with care coordination that the proxy reported.
BEHAVIORAL	Care coordination delivered based on usual care (e.g. discharge from hospital)	If a patient is discharged from a hospital, the patient will be selected for care management services.

Timeline

• Start date: 2022-12-05
• Primary completion: 2024-04-30
• Completion: 2024-04-30
• First posted: 2022-12-15
• Last updated: 2025-03-13
• Results posted: 2025-03-13

Locations

1 site across 1 country: United States