[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"health-study-detail:100647970":3},{"organization":4,"armGroups":7,"interventions":25,"overallOfficials":45,"centralContacts":50,"locations":58,"responsibleParty":183,"collaborators":24,"id":185,"slug":186,"hasResults":187,"nctId":188,"briefTitle":189,"officialTitle":190,"acronym":191,"eligibilityCriteria":192,"healthyVolunteers":187,"sex":193,"minAge":194,"maxAge":24,"enrollmentInfo":195,"targetDuration":24,"studyType":198,"phases":199,"briefSummary":201,"conditions":202,"keywords":206,"overallStatus":217,"whyStopped":24,"lastUpdateSubmitDate":218,"lastUpdatePostDateStruct":219,"startDateStruct":222,"completionDateStruct":224,"leadSponsor":226,"locationsCount":227},{"fullName":5,"class":6},"VA Office of Research and Development","FED",[8,15,20],{"label":9,"type":10,"description":11,"interventionNames":12},"EBP + Enhanced Implementation Support","EXPERIMENTAL","Four VA sites (and their associated practice groups) receive the virtual nurse and social worker palliative care intervention supported by enhanced implementation support. Enhanced support includes all standard components plus additional pre-implementation activities (baseline process mapping and a structured brainwriting premortem exercise), additional implementation activities (structured audit and feedback, iteratively updated process maps, and facilitation check-in meetings), and additional sustainability activities (check-in meetings and emails). Practice groups within these sites roll out in a stepped-wedge design with one practice group per wave across 6 waves.",[13,14],"Behavioral: Virtual Nurse and Social Worker Palliative Care Team","Behavioral: Enhanced Implementation Support",{"label":16,"type":10,"description":17,"interventionNames":18},"EBP + Standard Implementation Support","Four VA sites (and their associated practice groups) receive the virtual nurse and social worker palliative care intervention supported by standard implementation support. Standard support includes clinician engagement, clinician education and suggested implementation plans, fidelity monitoring, clinical office hours, adaptations tracking, sustainability planning, and dissemination of data and best practices. Practice groups within these sites roll out in a stepped-wedge design with one practice group per wave across 6 waves.",[13,19],"Behavioral: Standard Implementation Support",{"label":21,"type":22,"description":23,"interventionNames":24},"Usual Care (Pre-Implementation Control Period)","NO_INTERVENTION","Practice groups during their pre-implementation period provide usual care for eligible Veterans with heart failure or COPD without the virtual nurse and social worker team. In the stepped-wedge design, all practice groups eventually transition to their assigned intervention arm.",null,[26,33,39],{"type":27,"name":28,"description":29,"armGroupLabels":30,"otherNames":31},"BEHAVIORAL","Virtual Nurse and Social Worker Palliative Care Team","A virtual nurse and social worker team provides direct care to eligible Veterans with heart failure or COPD by phone or VA Video Connect. The nurse conducts structured symptom assessments and uses motivational interviewing to address the Veteran's most bothersome symptom (breathlessness, fatigue, depression, anxiety, or sleep disturbance).The social worker delivers brief structured counseling based on behavioral activation and interpersonal psychotherapy, including modules on activity goals, pacing, role change, and relaxation. The team engages in weekly collaborative case review with a representative primary care provider and palliative care physician and places orders for the treating PCP to consider. Nurses and social workers receive 8 hours of training in primary palliative care competencies.",[9,16],[32],"ADAPT intervention; palliative telecare team; nurse-social worker virtual team",{"type":27,"name":34,"description":35,"armGroupLabels":36,"otherNames":37},"Enhanced Implementation Support","Enhanced implementation support includes all standard support components plus: during pre-implementation, creation of baseline process maps and a structured brainwriting premortem exercise to identify implementation barriers; during implementation, structured audit and feedback, iteratively updated process maps, and facilitation check-in meetings; during sustainability, ongoing check-in meetings and emails. Delivered to across all phases (pre-implementation, implementation, and sustainability).",[9],[38],"Educational Outreach and Implementation Facilitation (enhanced)",{"type":27,"name":40,"description":41,"armGroupLabels":42,"otherNames":43},"Standard Implementation Support","Standard implementation support includes clinician engagement, clinician education and suggested implementation plans, fidelity monitoring, clinical office hours, adaptations tracking, sustainability planning, and dissemination of data and best practices. Delivered to across all phases (pre-implementation, implementation, and sustainability).",[16],[44],"Educational Outreach and Implementation Facilitation (standard)",[46],{"name":47,"affiliation":48,"role":49},"David Bekelman, MD MPH","Rocky Mountain Regional VA Medical Center, Aurora, CO","PRINCIPAL_INVESTIGATOR",[51,55],{"name":47,"role":52,"phone":53,"phoneExt":24,"email":54},"CONTACT","(720) 857-2809","david.bekelman@va.gov",{"name":56,"role":52,"phone":24,"phoneExt":24,"email":57},"Chelsea A Leonard, PhD","Chelsea.Leonard@va.gov",[59,79,96,115,132,149,166],{"facility":60,"status":24,"city":61,"state":62,"zip":63,"country":64,"countryCode":65,"cosmosGeoPoint":66,"geoPoint":71,"contacts":72},"Phoenix VA Health Care System, Phoenix, AZ","Phoenix","Arizona","85012","United States","US",{"type":67,"coordinates":68},"Point",[69,70],-112.07404,33.44838,{"lat":70,"lon":69},[73,76],{"name":74,"role":52,"phone":24,"phoneExt":24,"email":75},"Krystle Johnson-Reed, RN","krystle.johnson-reed@va.gov",{"name":77,"role":52,"phone":24,"phoneExt":24,"email":78},"Donna Seton, PA-C","donna.seton@va.gov",{"facility":80,"status":24,"city":81,"state":82,"zip":83,"country":64,"countryCode":65,"cosmosGeoPoint":84,"geoPoint":88,"contacts":89},"VA Long Beach Healthcare System, Long Beach, CA","Long Beach","California","90822",{"type":67,"coordinates":85},[86,87],-118.18923,33.76696,{"lat":87,"lon":86},[90,93],{"name":91,"role":52,"phone":24,"phoneExt":24,"email":92},"Donna Sheehan, RN","donna.sheehan@va.gov",{"name":94,"role":52,"phone":24,"phoneExt":24,"email":95},"Rebecca Yamarik, MD","rebecca.yamarik@va.gov",{"facility":48,"status":24,"city":97,"state":98,"zip":99,"country":64,"countryCode":65,"cosmosGeoPoint":100,"geoPoint":104,"contacts":105},"Aurora","Colorado","80045-7211",{"type":67,"coordinates":101},[102,103],-104.83192,39.72943,{"lat":103,"lon":102},[106,110,114],{"name":107,"role":52,"phone":108,"phoneExt":24,"email":109},"Pamela Rice, PhD","720-218-4015","Pamela.Rice@va.gov",{"name":111,"role":52,"phone":112,"phoneExt":24,"email":113},"James P Hill","(720) 830-7685","James.Hill5@va.gov",{"name":47,"role":49,"phone":24,"phoneExt":24,"email":24},{"facility":116,"status":24,"city":117,"state":118,"zip":119,"country":64,"countryCode":65,"cosmosGeoPoint":120,"geoPoint":124,"contacts":125},"Overton Brooks VA Medical Center, Shreveport, LA","Shreveport","Louisiana","71101-4243",{"type":67,"coordinates":121},[122,123],-93.75018,32.52515,{"lat":123,"lon":122},[126,129],{"name":127,"role":52,"phone":24,"phoneExt":24,"email":128},"Stephanie Branch, RN","stephanie.branch@va.gov",{"name":130,"role":52,"phone":24,"phoneExt":24,"email":131},"Marilyn Latin, MD","Marilyn.Latin@va.gov",{"facility":133,"status":24,"city":134,"state":135,"zip":136,"country":64,"countryCode":65,"cosmosGeoPoint":137,"geoPoint":141,"contacts":142},"Lebanon VA Medical Center, Lebanon, PA","Lebanon","Pennsylvania","17042-7529",{"type":67,"coordinates":138},[139,140],-76.41135,40.34093,{"lat":140,"lon":139},[143,146],{"name":144,"role":52,"phone":24,"phoneExt":24,"email":145},"Melissa Buchinski, RN","melissa.buchinski@va.gov",{"name":147,"role":52,"phone":24,"phoneExt":24,"email":148},"Rachel Causak, MD","Rachel.Causak@va.gov",{"facility":150,"status":24,"city":151,"state":152,"zip":153,"country":64,"countryCode":65,"cosmosGeoPoint":154,"geoPoint":158,"contacts":159},"Providence VA Medical Center, Providence, RI","Providence","Rhode Island","02908-4734",{"type":67,"coordinates":155},[156,157],-71.41283,41.82399,{"lat":157,"lon":156},[160,163],{"name":161,"role":52,"phone":24,"phoneExt":24,"email":162},"Patrician Lamarre, RN","patricia.lamarre@va.gov",{"name":164,"role":52,"phone":24,"phoneExt":24,"email":165},"Mitchell Wice, MD","mitchell.wice2@va.gov",{"facility":167,"status":24,"city":168,"state":169,"zip":170,"country":64,"countryCode":65,"cosmosGeoPoint":171,"geoPoint":175,"contacts":176},"Cheyenne VA Medical, Cheyenne, WY","Cheyenne","Wyoming","82001",{"type":67,"coordinates":172},[173,174],-104.82025,41.13998,{"lat":174,"lon":173},[177,180],{"name":178,"role":52,"phone":24,"phoneExt":24,"email":179},"Erin Kramer, RN","erin.kramer@va.gov",{"name":181,"role":52,"phone":24,"phoneExt":24,"email":182},"Jannene Sebesta, MD","jannene.sebesta@va.gov",{"type":184,"investigatorFullName":24,"investigatorTitle":24,"investigatorAffiliation":24,"oldNameTitle":24,"oldOrganization":24},"SPONSOR","100647970","virtual-nurse-and-social-worker-palliative-care-team-to-improve-quality-of-life-in-veterans-with-heart-failure-or-copd-100647970",false,"NCT07714252","Virtual Nurse and Social Worker Palliative Care Team to Improve Quality of Life in Veterans With Heart Failure or COPD","Addressing Symptoms With Person-Centered Treatment (ADAPT) (QUE 25-018)","VITALVET:ADAPT","Inclusion Criteria:\n\n* At least one primary care encounter in the past year, identified by primary care stop codes (301, 322, 323, 342, 348, 350, 704)\n* Diagnosed with heart failure, COPD, or interstitial lung disease, defined as 2 or more outpatient or community care provider visit encounters with a qualifying ICD code at least 30 days apart, or 1 inpatient hospitalization with a qualifying ICD code as the primary discharge diagnosis, within the past year\n* Care Assessment Need (CAN) 3.0 score ≥ 90 at some point in the prior 6 months\n* Poor self-reported quality of life, defined as a FACT-G score ≤ 70 at screening\n* Consistent access to a telephone\n\nExclusion Criteria:\n\n* Dementia diagnosis (any inpatient, outpatient, or community care encounter with qualifying ICD code in the prior 3 years)\n* Cancer diagnosis (2 or more outpatient or community care provider visit encounters, or 1inpatient primary discharge diagnosis, with a qualifying ICD code in the prior 1 year)\n* Current substance misuse (at least 1 inpatient or outpatient encounter with a qualifying substance\u002Falcohol ICD code or stop code in the prior 6 months)\n* Currently receiving palliative care (at least 1 inpatient or outpatient encounter with palliative care stop codes 351 or 353 in the prior 1 year)","ALL","18 Years",{"count":196,"type":197},420,"ESTIMATED","INTERVENTIONAL",[200],"NA","Many Veterans living with heart failure or chronic obstructive pulmonary disease (COPD) experience significant symptoms - such as breathlessness, fatigue, depression, and anxiety -that reduce their quality of life. Despite how common these symptoms are, they are often not adequately addressed in routine care. This study tests whether a virtual team of a nurse and social worker can improve quality of life, depression, anxiety, and other patient-reported outcomes for Veterans with heart failure or COPD who are at high risk of hospitalization or death. The nurse helps Veterans manage their most bothersome symptoms using a structured approach, and the social worker provides brief counseling to address emotional and psychological concerns. Both work closely with the Veteran's primary care provider and palliative care clinician to coordinate additional care as needed. The study also examines whether enhanced implementation support helps VA sites adopt the program more successfully compared to standard implementation support.",[203,204,205],"Heart Failure","Pulmonary Disease, Chronic Obstructive","Interstitial Lung Disease",[207,208,209,210,211,212,213,214,215,216],"Palliative Care","Quality of Life","Veterans Health","Telemedicine","Social Work","Implementation Science","Symptom Management","Patient-Reported Outcomes","Motivational Interviewing","Nurses","NOT_YET_RECRUITING","2026-07-15",{"date":220,"type":221},"2026-07-20","ACTUAL",{"date":223,"type":197},"2026-08-01",{"date":225,"type":197},"2030-09-30",{"name":5,"class":6},7]