Designing Care Management for Hospice Transitions for Persons Living With Advanced Dementia

Conditions

• Alzheimer Disease and Related Dementias

Eligibility Criteria

Sex

ALL

Age

18 Years - N/A

Healthy Volunteers

Accepted

Interventions

• Dementia Care Management Checklist for Hospice Transitions — BEHAVIORAL
  Intervention: After appropriate care partners of hospice-eligible PLWD are identified who will be receiving the checklist intervention, care managers will perform telephonic outreach to engage them in a conversation about care needs (as they would in typical clinical practice). The telephonic outreach will be followed up with a recommendation for follow up by a medical provider who may conduct a hospice care assessment and engage the care partner in decision-making surrounding the hospice referral and enrollment process. This intervention was co-designed with care partners, home healthcare professionals, administrators, and medical providers. It is meant to be comprehensive and speak to the needs of all relevant parties engaged in the care of persons with dementia. It is developed so that it can be scaled and implemented widely.

Study Details

This study will test a care management intervention to guide end-of-life care and hospice transitions for persons with dementia and their care partners receiving home healthcare and ascertain feasibility, acceptability, fidelity, and usability of a dementia care management hospice transitions checklist. This study will also examine hospice enrollment, time to enrollment, and care partner satisfaction with the intervention. The intervention will be delivered within usual care management within a large home healthcare agency.

Key Dates

First listed

Sep 19, 2025

Start date

May 13, 2026

Status verified

Jun 2026

Primary completion

Dec 31, 2027

Completion

Jul 31, 2028

Study Design

Enrollment

96 participants (estimated)

Allocation

NA

Intervention model

SINGLE_GROUP

Primary purpose

SUPPORTIVE_CARE

Arms

• Experimental: Dementia Care Management Checklist for Hospice Transitions
  The care management checklist will be administered to care partners by care managers during an outreach call to discuss the person with dementia's care and clinical needs. In this conversation, they will use the checklist to ask questions regarding care needs, decision-making considerations (healthcare proxy, etc), end-of-life dementia education, social and cultural needs, and potential care transitions.

Primary Outcome Measure

Feasibility of the Dementia Care Management Hospice Transitions Checklist [ Time Frame: After enrollment and study participation, we will collect feasibility data within 1 month after intervention receipt. ]

Central Contacts

• Komal P Murali, PhD, RN, ACNP-BC
  212-998-5783
  [email protected]

Locations (1)

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