RecruitingNot ApplicableNCT06616298

ALIGN for Older Adults With Cancer in SNFs

Improving Person-Centered Outcomes for Older Adults With Cancer Discharged to Skilled Nursing Facilities and Their Family Caregivers

Sponsor

University of Colorado, Denver

Enrollment

120 participants

Start Date

Feb 24, 2025

Study Type

INTERVENTIONAL

Conditions

Advanced Cancer

Summary

The goal of this clinical trial is to learn if it is possible to deliver a palliative care intervention called ALIGN (Assessing and Listening to Individual Goals and Needs) to hospitalized older adults with advanced cancer who are discharged to a skilled nursing facility and their caregivers. The main questions it aims to answer are: * Can the investigator successfully deliver the ALIGN intervention in different skilled community nursing facilities? * Can the investigator successfully collect information from participants throughout the study? * How can the investigator best prepare caregivers to make medical decisions for loved ones that become unable to do so themselves? Researchers will compare ALIGN to care as it is usually delivered. Participants will: * Visit virtually with an ALIGN palliative care social worker every 1-2 weeks during their skilled nursing facility stay and up to 45 days after discharge from the facility or will see a palliative care clinician if recommended by their oncologist or other involved clinician. * Participants will provide information about how they are doing 1 month, 3 months, and 6 months after enrolling in the study.

Eligibility

Min Age: 18 YearsMax Age: 98 Years

Inclusion Criteria15

Patients
Adults between 18-98 years
Stage II-IV solid tumors
Discharging from an acute care hospital to a SNF in Colorado
English speaking
Receiving or establishing care at the University of Colorado Cancer Center
If a patient lacks capacity, a legal surrogate decision-maker will be approached to provide proxy consent.
Must have access to the technology needed to complete consenting visit and subsequent intervention visits. This includes internet access through a computer, tablet, or smartphone OR cellular service with adequate allowance of cellular minutes to allow virtual visits (by participant\'s assessment).
Patient-selected
Age ≥ 18
English speaking
Able to complete baseline measures.
One of 25 interdisciplinary clinicians from the 5 most common community SNFs
Staff must be employed by on of the 5 most common community SNFs named above. (care managers, social workers, nurses, physical therapists, occupational therapists, advanced practice providers, and physicians)
\. PCSWs who conducted the ALIGN intervention and consent to an interview

Exclusion Criteria10

Discharging with hospice care
Age less than 18
Lacking capacity without a legal surrogate decision maker or proxy. Patient with limited English
Caregivers
Discharging with hospice care
Age \< 18
Caregivers with limited English proficiency will be excluded as ALIGN intervention content and documents have only been validated in an English-speaking population.
SNF Staff
\. Not employed by one of the top 5 community SNFs patients were discharged to during the pilot trial
PCSW

Interested in this trial?

Get notified about updates and connect with the research team.

Interventions

OTHERAssessing and Listening to Individual Goals and Needs (ALIGN)

Assessing and Listening to Individual Goals and Needs (ALIGN). ALIGN utilizes the skills of palliative care social workers (PCSWs) trained in family and systems-level theory to address changing preferences for care, family distress, and to facilitate communication across care transitions to improve care aligned with preferences. A patient navigator supports the patient/caregiver and social worker dynamic by helping patients access care and resources. The intervention is implemented virtually in community SNFs and follows patients for 45 days after SNF discharge to reflect real-world patient flow.