Health Teams Advancing Patient Experience: Strengthening Quality (TAPESTRY): A Randomized Controlled Trial Using the Health TAPESTRY Approach to Care for Older Adults
Overview
- Phase
- Not Applicable
- Intervention
- Not specified
- Conditions
- Aging
- Sponsor
- McMaster University
- Enrollment
- 316
- Locations
- 2
- Primary Endpoint
- Progress attaining health goals
- Status
- Completed
- Last Updated
- 8 years ago
Overview
Brief Summary
Health TAPESTRY is a delayed intervention pragmatic randomized control trial promoting interprofessional team collaboration, facilitating connection to the community through system navigation and trained community volunteers, enhancing communication and improving care through the use of technology to better understand and assist older adult patients in achieving their health goals and to enable them to have optimal aging.
Detailed Description
The overarching aim of the integrated multicomponent Health TAPESTRY approach is to promote optimal aging. Optimal aging within the Health TAPESTRY program means supporting people to move through life with good health in the best possible way: Being Alive Well. Health TAPESTRY is a health and social care approach that centres on meeting a person's health goals with the support of technology, trained community volunteers, an interprofessional team, system navigation, and better links between primary care and community organizations. The Health TAPESTRY intervention takes a complex, multilevel approach to integration, from both system level and individual level perspectives. The Health TAPESTRY program will provide processes and tools to activate and support individuals to access and use the broad range of available primary health care, social and community services to achieve their personal health goals and strategies to better integrate care at the system level. More specifically Health TAPESTRY will promote optimal aging: * through intentional, proactive conversations about a person's life, health and care goals within the primary healthcare setting; * through improved connections between inter-professional primary care teams, community service providers and informal caregivers; * by training volunteers to serve as a link between the primary care team and a person in their home; * by using technology from the home to link directly with the primary health care team which includes * the tablet-based Health TAPESTRY app for volunteers to use; * the Personal Health Record (PHR) and * innovative resources (i.e. Optimal Aging Portal). It is anticipated that together these will enable transformation of how primary healthcare and interprofessional teams provide care to older adults in a manner that provides value for resources used and meets needs and goals of older adults.
Investigators
Eligibility Criteria
Inclusion Criteria
- •Any community-dwelling patient of McMaster Family Health Team over the age of 70
Exclusion Criteria
- •Patient is palliative or receiving end-of-life care
- •Patient is deceased
- •Has explicitly stated that they do not want to be part of a research project
- •Patient resides in long-term care
- •Patient has indicated that they do not want to receive a home visit from trained community volunteers.
- •Patient or family member does not speak English
- •Patient will be out of the country for more than 50% of trial duration
Outcomes
Primary Outcomes
Progress attaining health goals
Time Frame: 12 months
The participant will identify up to 5 areas of health that will serve as the basis for Goal Attainment Scale(GAS) measurement and will assign subjective weights using a scale of 1 to 9 (higher scores indicating greater importance). An indicator for each goal is selected and used to indicate progress in meeting the goal. The expected outcomes for each problem area will be identified. These outcomes will be standardized and as descriptive, objective and observable as possible. The indicators will be applied to the intervention group and control group in the same manner. Participants will be followed up at the end of 6 months by an independent and blinded assessor for the purpose of study comparison to evaluate the patient's level of goal attainment for each priority problem area that has a goal attainment scale constructed for it although participants in the intervention group may have follow occur more frequently as the information about goals is transmitted to the health care team
Secondary Outcomes
- Quality of life measures (2 tools)(12 months)
- Self-efficacy Scale(12 months)
- Optimal aging(12 months)
- Duke Social Support Index(12 months)
- Comprehensiveness(12 months)
- Patient Empowerment(12 months)
- Patient Centredness(12 months)
- Access(12 months)
- Satisfaction with Care(12 months)
- Hospitalizations for Ambulatory Care Sensitive Conditions (ACSC) for Chronic Disease(12 months)
- Caregiver Strain Index(12 months)
- Cost-effectiveness(12 months)