In this study, participants will be randomly assigned to receive either the intervention or control treatment for up to 6 months. Participants in the intervention group will receive care from an intensive geriatric service worker (IGSW), who will help the participant:
(i) Coordinate community resources and actively support participants' instrumental activities of daily living (IADLs) (e.g., linking participants with Meals-on-Wheels, taking participants to appointments) (ii) Advocate for support from home care for completing activities of daily living (ADLs) (iii) Implement patients' prioritized treatment recommendations made by healthcare professionals (e.g., supporting patients to purchase and install home safety equipment because this aligns with their values and preferences).
Participants in the control group will receive their usual care, along with a booklet containing information about locally available resources, such as those related to meal preparation, grocery delivery, housekeeping, pharmacies that deliver medicines, home care, and Wheel-Trans.
We are interested in learning about the number and demographic characteristics of participants we will be able to recruit to the study, who will remain in the study and who will be adherent to their prioritized treatment recommendations. We are also interested in learning about changes in participants' quality of life, proportion of IADLs being completed independently or with support, emergency department visit rate, and hospitalization rate at 3 and 6 months.
None
None
Parallel
Intensive geriatric service worker model of care
Other interventionParticipants in the intervention group will receive care from an intensive geriatric service worker (IGSW), who will help the participant: (i) Coordinate community resources and actively support participants' instrumental activities of daily living (IADLs) (e.g., linking participants with Meals-on-Wheels, taking participants to appointments) (ii) Advocate for support from home care for completing activities of daily living (ADLs) (iii) Implement patients' prioritized treatment recommendations made by healthcare professionals (e.g., supporting patients to purchase and install home safety equipment because this aligns with their values and preferences).
Information brochure and telephone follow-up support
Other interventionParticipants will be e-mailed or mailed a booklet containing information about locally available resources including (1) meal preparation, (2) grocery delivery, (3) housekeeping, (4) pharmacies that deliver medications, (5) home care, and (6) Wheel-Trans. Participants will receive a scripted phone call from the study research coordinator one and three months after study enrolment to see if they have questions about the booklet material.
Implementation Feasibility
The number of participants (i) recruited (over the entire 12-month recruitment period and per month), (ii) retained (remain in the IGSW care model until prioritized recommendations are implemented, are discharged from the program because they are admitted to a retirement or LTC home, or complete the intervention; number of participants in the control group who provide follow-up data at 3 and 6 months) (iii) fully adherent to patients' prioritized recommendations during the trial period (% full adherence to \[a\] all prioritized recommendations, \[b\] \>75% of prioritized recommendations, and \[c\] ≥1 prioritized recommendation at 3 and 6 months) and (iv) sustained linkages to community agencies to provide ADL and IADL support (number of participants with linkages to \[a\] all community agencies, \[b\] ≥1 community agency at 3 and 6 months).
Quality of Life
Change in quality of life will be measured with the EQ-5D-5L
Proportion of IADLs being completed independently or with support
Emergency department visit rate
Hospitalization rate
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This trial is not recruiting at the moment. You can still explore other options:
