Inter-Disciplinary Outpatient Care Model Providing Comprehensive Geriatric Assessment, Care-Coordination & Co-management

Completed

• Conditions: Veterans; Geriatric Assessment; Care-Coordination; Outpatient Care

• Registration Number: NCT04846049
• Lead Sponsor: Miami VA Healthcare System

Brief Summary

Not available

Detailed Description

Not available

Study Timeline

• Study Start: 2019-3-5
• Last Update Posted: 2 September 2024

Recruitment & Eligibility

• Status: Completed
• Sex: All
• Target Recruitment: 206

Inclusion Criteria

Inclusion Criteria:<br><br> - Hospitalization in prior 12-months<br><br> - Received post-acute care in prior 12-months (skilled nursing facility or skilled<br> home health care)<br><br> - Two or more chronic conditions<br><br> - Two or more activity of daily living impairments or greater or equal to six Frailty<br> Index score<br><br> - Less than or equal to 60 minutes of closest VA primary care site.<br><br>Exclusion Criteria:<br><br> - Enrolled in Home Based Primary Care<br><br> - Using hospice Care<br><br> - Using palliative care<br><br> - In a foster home<br><br> - In a nursing home

Exclusion Criteria

Not provided

Study & Design

• Study Type: Observational
• Study Design: Not specified

Primary Outcome Measures

Name	Time	Method
Changes in FRAIL score;Change in Montreal Cognitive Assessment (MOCA)

Secondary Outcome Measures

Name	Time	Method
Katz Index of Independence in Activities of Daily Living;Lawton-Brody Instrumental Activities of Daily Living Scale;Detection of symptoms of depression;Change in number of clinic visits;Change in number of hospital admissions;Change in healthcare utilization