Half of older Americans visit the emergency department (ED) in the last month of life, making the ED a key decision point when doctors and nurses work with patients and families to establish a plan of care going forward. Palliative care interventions in the ED can both capture high-risk patients at a time of crisis and dramatically improve patient-centered outcomes by providing an extra layer of support for older adults and their caregivers. By testing novel models of care that can be delivered more efficiently, the project team hopes to build on the effectiveness of specialty palliative care demonstrated in ED patients admitted to the hospital. This proposal will generate comparative effectiveness research evidence to support the delivery of coordinated, community-based palliative care that effectively implements care plans that are consistent with the goals and preferences of older adults with advanced illness and their caregivers. The project team proposes a large, multisite study based in nine emergency departments (EDs) across the country to understand which model of palliative care in the community improves patient- and family-centered outcomes. The study will recruit a geographically, racially, and ethnically diverse group of older adults living at home with advanced cancer or end-stage organ failure, and their caregivers, upon visiting the ED. The team will compare two established palliative care models: nurse-led telephonic case management and specialty, outpatient palliative care. The models vary on the level of integration with patients’ other providers and whether palliative care is delivered via the outpatient clinic or at home, and in-person versus by telephone. The study will measure and evaluate patient- and caregiver-centered outcomes as primary and secondary end points, including quality of life, healthcare use, loneliness, and burden on caregivers. The proposal has strong endorsement and study participation from patient and organizational representatives, as well as a large Medicare Advantage plan that has implemented the nurse-led telephonic model on which one arm of the study is based. Specifically, the study will answer the following important question: When caring for older adults with serious, life-limiting illness discharged home after an ED visit, how effectively does nurse-led telephonic case management enhance quality of life and reduce healthcare use, loneliness, and burden on caregivers when compared with facilitated outpatient specialty palliative care?
*All proposed projects, including requested budgets and project periods, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award contract.