Care Transitions Program for Dementia

Overseen By Martyne Audet, MSc

Age: 65+

Sex: Any

Trial Phase: Academic

Sponsor: Laval University

Disqualifiers: Under 65, Long-term care, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Approved in 1 Jurisdiction This treatment is already approved in other countries

Compensation: Varies

Number of Visits: Unknown

700 Participants Needed

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial aims to enhance care coordination for individuals with major neurocognitive disorders, such as Alzheimer's, and their caregivers. It introduces the CoMPAS+ MNCD Program to streamline communication and support between healthcare providers and patients. The trial evaluates this program in various regions to assess its impact on care transitions, aiming to make the healthcare experience smoother for everyone involved. Individuals dealing with major neurocognitive disorders who have used healthcare services within the last six months might be suitable candidates for this trial. As an unphased trial, this study offers a unique opportunity to contribute to innovative care solutions and potentially improve the healthcare experience.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications. It's best to discuss this with the research team or your doctor.

What prior data suggests that the CoMPAS+ MNCD Program is safe for improving care transitions?

Research has shown that the CoMPAS+ MNCDs Program has been adjusted to improve the transition of care for people with major neurocognitive disorders (MNCDs). Previous studies found that the CoMPAS program can boost the well-being of people living with dementia and their caregivers, indicating that the program is generally safe and well-received.

This trial is labeled as "Not Applicable" in terms of phases, meaning it focuses on improving care coordination and processes rather than testing a new drug or medical device. Therefore, it does not carry the usual safety risks associated with trials for new medications. The main aim is to enhance how care is managed and delivered, which typically does not involve direct risks to participants. ^{1 2 3}

Why are researchers excited about this trial?

Researchers are excited about the CoMPAS+ MNCDs Program because it offers a fresh approach to managing dementia care transitions. Unlike traditional treatments that focus mainly on medications or isolated healthcare interactions, this program emphasizes coordinated workshops involving health professionals and caregiver partners across different care settings. This approach aims to enhance communication and collaboration between hospitals, primary care, and home care services, potentially leading to more seamless care experiences for patients. By integrating various healthcare providers, the program seeks to reduce hospital visits and improve overall care quality for individuals with dementia.

What evidence suggests that the CoMPAS+ MNCDs Program could be effective for improving care transitions in dementia?

Research has shown that the CoMPAS+ program, which participants in this trial may experience through various local service networks, can improve the transition of care for patients with major memory disorders, such as Alzheimer's disease. Studies have found that programs like CoMPAS+ enhance communication and teamwork among healthcare providers, leading to better outcomes for patients and their caregivers. Specifically, the program has successfully enhanced the well-being of people with dementia and their caregivers by promoting communication focused on the individual. This ensures that care is tailored to the patient's specific needs and preferences. These improvements in care coordination can lead to a smoother healthcare experience for patients and their families. ^{2 4 5}

Who Is on the Research Team?

Patrick M Archambault, MD, MSc, FRCPC

Principal Investigator

Laval University

Are You a Good Fit for This Trial?

This trial is for older adults with major neurocognitive disorders like Alzheimer's, and their caregivers. It focuses on improving care transitions between healthcare providers to enhance coordination and support.

Inclusion Criteria

Consent to the research team collecting data from the medical records of the person being cared for (FMG Electronic Medical Record (EMR) when accessible, Hospital Electronic Patient Record (EPR) when accessible, etc.)

Be a participant in the CoMPAS+ MNCD workshops and be part of at least one of the following categories of participants: Health professionals working in a CISSS CA health facility or with a community organization, CISSS CA decision-makers or local managers, Community service representative (e.g., Alzheimer's Society, L'APPUI)

Be able to consent independently to research and reside at home, in a retirement home, in an intermediate residence, or a family-type resource

Exclusion Criteria

I do not agree to share my medical records for this trial.

User living in a provincial long-term care facility at the time of recruitment

I am over 65, have a significant memory or thinking problem, and cannot consent to research on my own without a caregiver.

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Implementation

Implementation of the CoMPAS+ MNCD Program through workshops and interventions in Local Services Networks

12-15 months

Multiple workshops and interventions

Follow-up

Participants are monitored for the impact of the Program on care transitions, quality of life, and caregiver burden

15 months

Telephone questionnaires at multiple time points

Evaluation

Evaluation of the Program's sustainability and scale-up potential through focus groups and interviews

12-15 months

What Are the Treatments Tested in This Trial?

Interventions

• CoMPAS+ MNCDs Program

Trial Overview

The CoMPAS+ MNCDs Program is being tested, which aims to improve the quality of care transitions for patients with neurocognitive disorders through better practices and local solutions in Family Medicine Groups.

How Is the Trial Designed?

Group I: Local Services Network (LSN) Montmagny-L Islet Experimental Treatment 1 Intervention

The local services network (LSN) Montmagny-L'Islet is set in a semi-urban region with a small community hospital. The CoMPAS+ TNCM workshops (intervention) in the LSN Montmagny-L'Islet will be conducted with health professionals and careviver partners from the FMG of Montmagny (GMF de Montmagny) which comprises the organisational merging of 5 different medical clinics in the region. Will also participate in the workshops are healthcare professionals from the home care services team, and from the emergency department of the Hopital de Montmagny. The population that will be recruited to evaluate the impact of the intervention will have either 1) received home care services within the last 6 months before the intervention; 2) visited the emergency department of Hopital de Montmagny within the last 6 months before the intervention; or 3) consulted with their family doctor within the last 6 months before the intervention.

Group II: Local Services Network (LSN) Bellechasse Experimental Treatment 1 Intervention

The local services network (LSN) of Bellechasse is set in a rural area. The population requiring urgent medical care are lead to Hotel-Dieu de Lévis (45 km, Alphonse-Desjardins) or Hopital de Montgagny (30 km, Montmagny-L'Islet). The CoMPAS+ TNCM workshops (intervention) in the LSN of Bellechasse will be conducted with health professionals and caregiver partners from the FMG Rive de l'Etchemin (GMF Rive de l'Etchemin) which comprises the organisational merging of 2 medical clinics. Will also participate in the workshops members the home care team. The population that will be recruited to evaluate the impact of the intervention will have either 1) received home care services within the last 6 months before the intervention; 2) visited one of the 2 emergency departments (Hotel-Dieu de Lévis or Hopital de Montmagny) within the last 6 months before the intervention; or 3) consulted with their primary care team within the last 6 months before the intervention.

Group III: Local Services Network (LSN) Alphonse-Desjardins Experimental Treatment 1 Intervention

The local services network (LSN) Alphonse-Desjardins is set in a urban region with the most important community hospital of the greater region of Chaudière-Appalaches. The CoMPAS+ TNCM workshops (intervention) in the LSN Alphonse-Desjardins will be conducted with health professionals and caregiver partners from the FMG of Lévis (GMF-U de Lévis), the home support services team, and the emergency department of the Hotel-Dieu de Lévis. The population that will be recruited to evaluate the impact of the intervention will have either 1) received home care services within the last 6 months before the intervention; 2) visited the emergency department of Hotel-Dieu de Lévis within the last 6 months before the intervention; or 3) consulted with their primary health care team within the last 6 months before the intervention.

Who Is Running the Clinical Trial?

Laval University

Lead Sponsor

Trials

439

Recruited

178,000+

Institut national d'excellence en santé et service sociaux

Collaborator

Trials

1

Recruited

700+

CISSS de Chaudière-Appalaches

Collaborator

Trials

9

Recruited

16,500+

Published Research Related to This Trial

Older adults with dementia experience significantly higher rates of nursing facility use, hospitalizations, and transitions in care compared to those without a dementia diagnosis, indicating a complex care trajectory.

Most transitions to nursing facilities for individuals with dementia occur after hospitalizations, highlighting the interconnectedness of care settings and the need for coordinated support during these transitions.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Transitions in care for older adults with and without dementia. Callahan, CM., Arling, G., Tu, W., et al.[2022]

A partnership project aimed at improving care transitions for hospitalized seniors was implemented, focusing on three key levels: organizational agreements, unit-level adjustments, and individual care plans.

The project included tools like a transition checklist and customized supports, which helped enhance acceptance and facilitate safer transitions for seniors with complex medical and mental health needs.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Improving transitions between acute mental health and residential care. McLennan, M., Kurucz, S., Fudge, H.[2019]

A study analyzing discharge documentation for 60 older adults with dementia revealed that only 17% of the documentation met excellent standards for transitional care needs, indicating significant gaps in the quality of information provided during care transitions.

The variability in discharge documentation quality (37% excellent, 43% adequate, and 20% poor) highlights the urgent need for improvements to ensure safe and effective care for individuals with dementia moving from hospital to nursing home settings.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Analysis of discharge documentation for older adults living with dementia: A cohort study. Parker, KJ., Phillips, JL., Luckett, T., et al.[2021]

The National Institute on Aging IMPACT Collaboratory aims to enhance the integration of evidence-based care for over 5 million persons living with dementia and their caregivers by funding up to 40 pilot embedded pragmatic clinical trials (ePCTs) focused on nonpharmacologic interventions.

Initial findings from the pilot core revealed that many investigators are unfamiliar with ePCTs and that proposed studies often lack essential design elements, leading to the establishment of three key criteria for future pilot studies to ensure their viability.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Building a National Program for Pilot Studies of Embedded Pragmatic Clinical Trials in Dementia Care. Brody, AA., Barnes, DE., Chodosh, J., et al.[2021]

The ADMIT Me tool was developed to improve safe transitions of care for individuals with Alzheimer's and dementia, based on feedback from focus groups involving caregivers, emergency department nurses, and first responders.

Participants in the focus groups unanimously agreed that the ADMIT Me tool would enhance safety during care transitions by promoting clear communication and collaboration among healthcare providers, ultimately leading to more patient-centered care.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Enhancing the ADMIT Me Tool for Care Transitions for Individuals With Alzheimer's Disease. Moore, JR., Sullivan, MM.[2018]

The Dementia Cal MediConnect project, a 5-year initiative involving local Alzheimer's organizations and 10 managed care health plans in California, successfully implemented systems changes to improve dementia care, including better detection, diagnosis, and support for caregivers.

The advocacy model used in this project demonstrated that targeted efforts can enhance dementia-capable practices within healthcare systems, suggesting that similar approaches could be beneficial in other regions to better serve people living with dementia.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Building an advocacy model to improve the dementia-capability of health plans in California. Hollister, BA., Yeh, J., Ross, L., et al.[2021]

The Systematic Care Program for Dementia (SCPD) did not significantly reduce the rate of institutionalization for dementia patients after 12 months, despite being implemented across six community mental health services with 295 patient-caregiver dyads.

Key predictors of institutionalization included the caregiver's sense of competence and depressive symptoms, as well as the patient's behavioral issues and severity of dementia, highlighting the importance of caregiver support in managing dementia.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Systematic care for caregivers of patients with dementia: a multicenter, cluster-randomized, controlled trial. Spijker, A., Wollersheim, H., Teerenstra, S., et al.[2017]

An integrative review identified 71 reports on measures of care transitions and coordination for individuals living with dementia, highlighting the need for better evaluation of these measures in terms of person- and family-centered care.

While some measures were effective in assessing outcomes like healthcare use and costs, there was significant variability in definitions and time requirements for data collection, indicating a need for improved and standardized measures in future research.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

An integrative review of measures of transitions and care coordination for persons living with dementia and their caregivers. Hirschman, KB., McHugh, M., Morgan, B.[2023]

In a study of 16,186 older adults with dementia, 21.3% experienced frequent transitions in care, highlighting the instability in their living situations, with many moving between home, hospitals, and nursing facilities.

Among those with moderate to severe dementia, a significant number transitioned back home after hospital stays, indicating that even severely impaired individuals frequently change care settings, which can complicate their management and support.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Transitions in Care in a Nationally Representative Sample of Older Americans with Dementia. Callahan, CM., Tu, W., Unroe, KT., et al.[2022]

In a study of 31,648 community-dwelling older veterans with dementia, a higher continuity of care (COC) score was associated with a 4.6% increased likelihood of successful direct discharge to the community after hospitalization.

However, the impact of COC was not significant for discharges through post-acute care facilities, suggesting that while better continuity may help some patients, its overall effect is small and requires further investigation.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Continuity of Care and Successful Hospital Discharge of Older Veterans With Dementia. Lei, L., Cai, S., Conwell, Y., et al.[2022]

Individuals newly diagnosed with dementia experience a significant increase in care transitions, particularly hospitalizations, during the year of diagnosis, indicating a critical period for intervention.

Receiving recommended dementia care and high-quality primary care is linked to fewer transitions across care settings, suggesting that improved care can help manage the complexities faced by dementia patients.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Diagnosis and Disruption: Population-Level Analysis Identifying Points of Care at Which Transitions Are Highest for People with Dementia and Factors That Contribute to Them. Sivananthan, SN., McGrail, KM.[2022]

The novel dementia care coordination program did not significantly reduce the use of acute care or inpatient services, but it did lead to an increase in outpatient dementia and mental health visits over 18 months, indicating improved access to specialized care.

Participants in the intervention group significantly increased their use of home and community-based support services, suggesting that the program may help individuals with dementia remain in their homes longer and receive necessary support.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Health Services Utilization in Older Adults with Dementia Receiving Care Coordination: The MIND at Home Trial. Amjad, H., Wong, SK., Roth, DL., et al.[2019]

The Laval-ROSA Transilab aims to enhance care for people living with dementia by improving transitions between different healthcare settings through targeted innovations, including training for primary care professionals and an early referral process to community services.

The project employs a multi-methods living lab approach, involving co-development and co-evaluation of strategies to ensure sustainable improvements in dementia care, ultimately benefiting patients, caregivers, and healthcare providers.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Research protocol of the Laval-ROSA Transilab: a living lab on transitions for people living with dementia. Dufour, I., Arsenault-Lapierre, G., Guillette, M., et al.[2023]

Embedded pragmatic clinical trials (ePCTs) can effectively utilize existing healthcare data, such as Medicare claims and electronic health records, to improve research on Alzheimer's disease and related dementias, which often involve complex care settings.

These ePCTs are particularly valuable for people living with dementia, as they allow for better case identification and integration of diverse care environments, enhancing the relevance and applicability of research findings in real-world scenarios.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Using Healthcare Data in Embedded Pragmatic Clinical Trials among People Living with Dementia and Their Caregivers: State of the Art. Bynum, JPW., Dorr, DA., Lima, J., et al.[2021]

Community care coordination has shown promise in reducing the rate of nursing home admissions for older people with dementia, with a significant risk ratio of 0.66 based on data from 303 participants across two studies.

Other non-pharmacological interventions, such as psychoeducation and multifactorial approaches, did not demonstrate a significant effect on preventing hospital or nursing home admissions, suggesting that not all interventions are equally effective.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Non-pharmacological interventions to prevent hospital or nursing home admissions among community-dwelling older people with dementia: A systematic review and meta-analysis. Lee, DA., Tirlea, L., Haines, TP.[2021]

Citations

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Study Details | NCT06608589 | CONSTELLATIONS Living ...

In this study, the investigators adapt COMPAS+ to focus on improving care transitions for patients with major neurocognitive disorders (MNCDs) and their ...

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Efficacy of COMPAs, an App Designed to Support ...

Conclusions: COMPAs intervention improved well-being in persons living with dementia and their caregivers by developing person-centered ...

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pubmed.ncbi.nlm.nih.gov/38963691/

Efficacy of COMPAs, an App Designed to Support ...

COMPAs intervention improved well-being in persons living with dementia and their caregivers by developing person-centered communication within the dyad.

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clinicaltrials.gov

clinicaltrials.gov/study/NCT06608589

Improving the Care Transitions of Older Adults Living with ...

In this study, the investigators adapt COMPAS+ to focus on improving care transitions for patients with major neurocognitive disorders (MNCDs) and their ...

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reporter.nih.gov

reporter.nih.gov/search/NVKuxbzo-0GpaWWIDhmMoQ/project-details/10984394

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