What's in the Black Box of a Successful Nurse and Social Worker Team Palliative Telecare Intervention (ADAPT)? (RP317)

Outcomes 1. Describe the content delivered in the nurse and social worker palliative telecare team intervention.2. Summarize the most common recommendations provided by the collaborative care team in the ADAPT intervention. Key Message A nurse and social worker palliative telecare team provided structured symptom management, psychosocial care, and individualized medical changes to improve quality of life, depression, and anxiety for patients with COPD, HF, and ILD. Importance In a multi-site RCT, a nurse and social worker palliative telecare team (ADAPT) improved quality of life, disease-specific health status, depression, and anxiety among patients with COPD, HF, and ILD. Understanding intervention content and processes will help with implementation in different contexts. Objective(s) To summarize the content and processes of the core components of the ADAPT intervention as it was delivered. Scientific Methods Utilized Intervention processes were prospectively tracked. We used descriptive statistics to examine the 3 intervention components: 1) symptom care by a registered nurse (RN), 2) psychosocial care by a social worker (SW), and 3) weekly interdisciplinary collaborative care team (CCT) meetings, including the RN, SW, an internist, a palliative care specialist, and as needed cardiologist and pulmonologist, to make recommendations (many of which were subject to approval by participant's primary care clinician) to improve patient quality of life. Results Participants (n=153) averaged 8.6 (SD 2.9) visits with the RN, with mean visit length of 42.1 minutes (SD 23.7). Participants averaged 7.3 (SD 2.26) visits with the SW, with mean visit length of 46.4 (SD 22.1) minutes. Over half of the visits (56.2%) were joint visits with both the SW and the RN. 76.5% (n=117) completed all required social work and nurse visits. The CCT discussed each participant an average of 3.7 (SD 1.8) times and made 7 (SD 3.8) recommendations per participant. Of 148 participants who received a recommendation from the CCT, 79.7% (n=118) of participants received a consult recommendation (e.g., mental health, sleep clinic, cardiac/pulmonary clinic), 63.5% (n=94) received a recommendation related to achieving the participant's selected goal (e.g. increase physical activity, start using CPAP consistently) 58.1% (n=86) a medication addition, 33.1% (n=49) had a test ordered, 31.8% (n=47) a medication changed, 21.6% (n=32) lab ordered, 21% (n=31) received a handout (e.g. CPAP education, community resources, advanced care planning), and 15.5% (n=23) had a medication discontinued. Conclusion(s) Most participants completed all RN and SW visits, over half of which were RN and SW joint visits. CCT recommendations were diverse and individualized to address a variety of participant symptoms and needs. Impact A nurse and social work palliative telecare team used collaborative care to tailor recommendations to the unique needs and symptoms of each patient, thereby improving quality of life. Keywords Models of palliative/hospice care delivery/Palliative care in chronic, non-malignant illness