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Tier Palliative Care For Patients With Advanced Heart Failure or Cancer

RecruitingNAAges 18 Years - anyAllIcahn School of Medicine at Mount Sinai
NCT07391956 on ClinicalTrials.gov ↗
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In plain words

What the trial is, and whether it could suit you

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 sym

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📋 Eligibility rules (as published)
Inclusion Criteria: * 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 * Manhattan or Queens residence * Capacity to provide informed consent * English or Spanish fluency * \> or = 18 years of age Exclusion Criteria: * 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 * Previous receipt of a ventricular assist device or previous heart transplantation * Receiving hospice care prior to study enrollment or enrolled in another study of a palliative care patient/caregiver intervention * Living in a facility (subacute rehab, long-term care facility, hospice facility or residence) * Callahan 6-Item Cognitive Screening score ≤3
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What it tests

  • Tier-Palliative Care
  • Community Health Worker
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Where

5 sites
Mount Sinai Queens
Astoria, United States
Mount Sinai Downtown
New York, United States
Mount Sinai West
New York, United States
Mount Sinai Morningside
New York, United States
Mount Sinai Hospital
New York, United States
🤝 Taking part is your choice, and you can leave at any time. Only the trial team can confirm you are eligible — always decide together with your own doctor.
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