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.
Advanced Heart Failure (HF) with two HF-related hospitalizations within the last 12 months or
Advanced lung or non-colorectal gastrointestinal cancer (pancreatic, gastric, hepatobiliary, small bowel, esophageal) or tripe negative breast cancer with one hospitalization within the last 6 months
KPS > or = 50% (ECOG 0, 1 or 2)
> 2 outpatient MSHS visits in prior 12 months
Diagnoses of both cancer and advanced HF
Lung cancer with a driver mutation (e.g., EGFR) that confers a favorable prognosis and does not follow typical trajectory
Patients with > 1 visit to Outpatient Supportive Oncology/Cardiology visit
Patients with last visit to Outpatient Supportive Oncology/Cardiology < 3 months ago
Parallel
Tier-Palliative Care
BehavioralTIER-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.
Community Health Worker
BehavioralUsual Care plus the addition of a community health worker who will serve as a health coach for the participant.
Edmonton Symptom Assessment Scale (ESAS)
Patient symptoms: Edmonton Symptom Assessment Scale (ESAS), 9 items, each item is scored on a 10-point scale, total score ranges from 0-90, higher scores indicate more symptoms.
Functional Assessment of Chronic Illness Therapy-Palliative Care Scale (FACIT-Pal)
Patient quality of life: Functional Assessment of Chronic Illness Therapy-Palliative Care Scale (FACIT-Pal), a 46-item QoL questionnaire validated in patients with advanced disease. Each item is scored on a 5-point likert scale. Total score ranges from 0-184, higher scores indicate better quality of life
Patient-reported goals of care discussion
Patient-reported Goals of Care Discussions: "Have you ever discussed with this doctor the kind of medical care you would want if you were too sick to speak for yourself?" Response: Yes/No
Generalized Anxiety Disorder-7 (GAD-7)
Generalized Anxiety Disorder-7 (GAD-7), a 7-item scale, Full scale from 0-21, higher scores indicates more anxiety.
Family Satisfaction with End-of-Life Care (FAMCARE-10)
FAMCARE-10 to assess caregiver satisfaction by using a validated 10-item structured questionnaire administered to patient-subjects via telephone interview or in person by the trained research coordinator. Full scale ranges 0-20, with higher scores indicating higher satisfaction.
Number of hospital admissions
Number of hospital admissions: Acute care utilization as measured by the number of hospital admissions
Number of hospital days
Number of hospital days: Acute care utilization as measured by the number of hospital days
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Icahn School of Medicine at Mount Sinai
Lead sponsor
National Institute of Nursing Research (NINR)
Collaborator
