Trial of Mount Sinai Palliative Care at Home

The objective of this randomized controlled trial is to study the impact of a new home based
palliative care program on patients' symptoms, quality of life, satisfaction with care,
completion of advance care planning documentation and receipt of care consistent with
preferences. In addition, the study will examine the impact of this model of care on patient
healthcare utilization, including hospitalization, emergency department utilization, and
hospice use prior to death. The trial will also include patients' caregivers, in order to
examine the impact of the intervention on caregiver burden and prevalence of depression.

Patients randomized to the intervention will be scheduled for an intake visit. This visit
will be undertaken by the team's registered nurse and/or social worker, together with a
community health worker, and other team members (advanced practice nurse, MD), depending on
patients' needs. Following this visit, and in conjunction with the nurse practitioner and/or
MD, a care plan will be developed to address areas of clinical need highlighted during the
intake visit.

Patients in the intervention arm will receive ongoing monitoring and input (telephone-based
and in-person) from members of the clinical team, dependent on their identified needs.
Patients' cases will be discussed at the weekly IDT meeting, as appropriate to the level of
clinical need. Patients and caregivers will be provided with access to a 24 hour telephone
line, staffed by a Mount Sinai based physician, which acts as an advice line out of hours.
These physicians will be able to provide advice to patients and caregivers.

Inclusion Criteria:

- Presence of a "serious medical illness" - according to pre-specified diagnostic
code-based criteria

- Subject has a Mount Sinai physician who authorizes their participation in the study
and receipt of the program

- Subject is resident in Manhattan outside of a long term care facility and is not
receiving hospice 5.

- Subject has evidence of capacity to benefit from enrollment in palliative care program

- Subject is conversant in English or Spanish

- Subject has capacity to consent

Exclusion Criteria:

- Subject has no usual physician within Mount Sinai

- Subject's usual physician doesn't provide authorization to patient participation

- Subject resident outside of Manhattan or in long term care facility or receiving
hospice

- Subject is not conversant in English or Spanish

- Subject cannot provide informed consent to participation

- Dementia (where the subject does not have the capacity to consent)