Improving Person-Centered Outcomes for Older Adults with Cancer Discharged to Skilled Nursing Facilities and their Family Caregivers
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PROJECT SUMMARY/ABSTRACT: Dr. Singh’s long-term goal is to lead research efforts that enhance delivery of palliative care to improve person-centered outcomes for hospitalized older adults with advanced cancer discharged to skilled nursing facilities (SNFs) and their family caregivers. The current model of SNF care is inadequate to meet the unique needs of these patients who often experience rapid clinical decline due to the juxtaposition of comorbidities and geriatric syndromes which places them at risk for receiving goal- discordant care. Palliative care nursing home interventions have been challenging to implement and have targeted long-stay residents who have different needs than SNF patients. Dr. Singh is a physician in the Division of Hospital Medicine at the University of Colorado. Her proposal tests the ALIGN (Assessing and Listening to Individual Goals and Needs) intervention which utilizes palliative care social workers to deliver a guideline-based manualized intervention for older patients with cancer discharged to SNFs and their family caregivers. In a preliminary study funded by the National Palliative Care Research Center, Dr. Singh demonstrated that virtual ALIGN visits could be conducted in community SNFs and that the intervention was highly acceptable. Patients experienced high morbidity and mortality leading many to change their goals to comfort focused care and necessitating increased family caregiver involvement in surrogate decision making. This K23 proposal aims to address key gaps and strengthen ALIGN for future clinical efficacy testing. The objectives are to: 1) conduct a pilot randomized controlled trial to test feasibility of enrolling participants into a randomized design, outcome collection, preliminary efficacy, and risk for contamination; 2) evaluate implementation outcomes, including intervention fidelity, of ALIGN in community SNFs; 3) determine processes through which ALIGN prepares caregivers for surrogate decision making to iteratively refine the intervention to improve goal concordant care. The proposed training plan is designed to accelerate Dr. Singh’s development into an independent patient-oriented researcher and includes training in clinical trial design and analysis, implementation science, caregiver focused palliative care interventions, and preparation for independence. Dr. Singh has assembled an exceptional mentorship team, led by Dr. Stacy Fischer, with complementary expertise in clinical trials in an oncology population, palliative care social work, nursing home research, implementation science, surrogate and end of life decision making, and caregiving research. The K23 award would enable Dr. Singh to continue developing her research skills while providing her with data to prepare an R01 proposal for a fully powered clinical trial of ALIGN evaluating efficacy. Successful completion of this research will inform the development of a scalable model of palliative care that can be implemented in community SNFs to maximize real-world effectiveness. Further, it will expand our understanding of how to best prepare family caregivers for surrogate decision making to improve delivery of care aligned with patient preferences after discharge to SNF.
