Improving care transitions for older adults with neurocognitive disorders

CONSTELLATIONS Living Lab: Development, Implementation and Evaluation of a Patient-oriented Quality Improvement Program Targeting Care Transitions of Older Adults Living with Major Neurocognitive Disorders and Their Caregivers.

This study is testing new ways to help older adults with Alzheimer’s and dementia get better support when moving between different healthcare services.

Quick facts

• Phase: Not applicable
• Study type: Interventional
• Enrollment: 700 (estimated)
• Ages: 65 Years and up
• Sex: All
• Sponsor: Laval University (Academic / other)
• Locations: 1 site (Québec, Quebec)
• Trial ID: NCT06608589 on ClinicalTrials.gov

What this trial studies

This initiative focuses on enhancing the care transitions of older adults living with major neurocognitive disorders, such as Alzheimer's disease and dementia. It aims to address the challenges faced by patients and caregivers due to inefficient communication and coordination within the healthcare system. The CoMPAS+ MNCDs Program will implement quality improvement strategies to facilitate better collaboration among healthcare providers and improve the overall care experience for these individuals. The program is designed to evaluate its impact on the quality of care transitions for both patients and their caregivers.

Who should consider this trial

Good fit: Ideal candidates include individuals aged 65 and older living with a major neurocognitive disorder or their caregivers.

Not a fit: Patients who are younger than 65 or do not have a major neurocognitive disorder may not benefit from this program.

Why it matters

Potential benefit: If successful, this program could significantly improve the quality of care and support for older adults with neurocognitive disorders and their caregivers.

How similar studies have performed: Other studies have shown success in improving care transitions for older adults with chronic conditions, indicating that this approach has potential.

Eligibility criteria

Study population for the evaluation of the impact of the CoMPAS+ MNCD Program on the care transitions of patients living with MNCD and their caregivers (Micro level)

Inclusion criteria:

* Be 65 years of age or older;
* Be living with a major neurocognitive disorder in the process of clinical evaluation or already diagnosed;
* Reside in the socio-sanitary region of the CISSS CA;
* Be able to consent independently to research (for users without caregivers at the beginning of their illness);
* Reside at home or in a retirement home or in an intermediate residence or a family-type resources;
* Consent to the research team collecting data in their medical records (FMG Electronic Medical Record (EMR) when accessible, Hospital Electronic Patient Record (EPR) when accessible, etc.).

OR

* Be the caregiver of a person 65 years of age and older living with a major neurocognitive disorder in the process of clinical evaluation or already diagnosed;
* The person being cared for must reside in the socio-sanitary region of the CISSS CA;
* Consent to the research team collecting data from the medical records of the person being cared for (FMG Electronic Medical Record (EMR) when accessible, Hospital Electronic Patient Record (EPR) when accessible, etc.);
* Be able to consent independently to research.

Exclusion criteria:

* Users living with major neurocognitive disorder under 65 years of age;
* User living in a provincial long-term care facility at the time of recruitment;
* User 65 years of age and older living with a major neurocognitive disorder, unable to consent independently to research, without a caregiver, or without a caregiver able to consent independently to research;
* Users aged 65 and over living with a major neurocognitive disorder, residing in a territory other than that of the CISSS CA;
* User refusing to consent to the collection of data in their medical records; OR
* Caregiver of a user living with a major neurocognitive disorder who does not reside in the CISSS CA territory or who is not 65 years of age or does not live at home, in a retirement home or in an IR or who died before the start of the study (T=0).
* Caregiver refusing to consent to the collection of data in the medical records of the person being cared for.

Study population for the assessment of the intention to apply best practices of CoMPAS+ MNCD workshop participants (Meso level)

Inclusion criteria:

● Be a participant in the CoMPAS+ MNCD workshops and be part of at least one of the following categories of participants:

* Health professionals working in a CISSS CA health facility or with a community organization;
* CISSS CA decision-makers or local managers;
* Community service representative (e.g., Alzheimer's Society, L'APPUI);

Exclusion criteria:

* Research team members
* Workshop facilitators
* INESSS professionals
* Users and partner caregivers
* Person unable to consent
* Person refusing to consent

Study population for the evaluation of the potential to scale-up and sustainability of the CoMPAS+ MNCD Program within the CISSS CA (Meso level)

Inclusion criteria

● Be part of one of the following categories of actors and be involved in the implementation of the CoMPAS+ MNCD Program:

* Health professionals working at the CISSS CA or in the community participating in the CoMPAS+ MNCD workshops;
* CISSS CA decision-makers;
* Users and partner caregivers;
* Community service representatives (e.g., Alzheimer's Society, L'APPUI);
* Members of the research team (except the person in charge of this component (Laetitia Bert), Alexander Cornea (research assistant), Martyne Audet (scientific coordinator), Clémence Dallaire, André Côté, Félix Pageau, Catherine Paquet);
* Research coordinator responsible for the involvement of partner users in the conduct of the workshops (Émilie Côté);
* INESSS professionals;
* Workshop facilitators
* Representative of the Ministry of Health and Social Services (MSSS).

Exclusion criteria

* Person unable to consent;
* A person refusing to consent;
* Member of the research team responsible for carrying out this part of the study or by the scientific coordination of this project (Laetitia Bert, Alexander Cornea, Martyne Audet (scientific coordinator), Clémence Dallaire, André Côté, Félix Pageau, Catherine Paquet).

Where this trial is running

Québec, Quebec

• Patrick Archambault — Québec, Quebec, Canada (Recruiting)

Study contacts

• Principal investigator: Patrick M Archambault, MD, MSc, FRCPC — Laval University
• Study coordinator: Patrick M Archambault, MD MSc FRCPC

Conditions Alzheimer Disease; Dementia; Neurocognitive Decline; Quality improvement; Older adults; Learning Health Systems; Implementation science; Health care utilisation