CONSTELLATIONS Living Lab: Improving the Care Transitions of Older Adults Living with Neurocognitive Disorders
Condition(s) studied
Investigational drug(s) / intervention(s)
CoMPAS+ MNCDs Program - Quality improvement program targeting the care transitions of patients living with a major neurocognitive disorder and their caregivers: COMPAS+ is a collaborative approach to improving healthcare quality. It brings together around 30 individuals, including healthcare professionals, deciders, and patient partners, to identify improvement goals, develop action plans, and enhance the prevention and management of chronic diseases. In this study, the investigators adapt COMPAS+ to focus on improving care transitions for patients with major neurocognitive disorders (MNCDs) and their caregivers. Through reflective workshops and collaborative problem-solving, this diverse group will identify best practices and create action plans to enhance care quality.
Study summary
The prevalence of major neurocognitive disorders (MNCDs), particularly Alzheimer's disease, among older adults is increasing. These individuals and their caregivers often face challenges due to inefficient and poorly coordinated care transitions, negatively impacting patients, caregivers, healthcare professionals, and the healthcare system itself. To address this, the Quebec Ministry of Health and Social Services has released Phase 3 of its Ministerial Guidance on Major Neurocognitive Disorders, aiming to enhance care coordination between primary healthcare professionals and those living with MNCDs and their caregivers.
Quebec's healthcare system comprises various organizations providing care and services to individuals with MNCDs. Each organization faces unique challenges hindering improvement initiatives. However, common obstacles persist: inadequate communication systems for sharing vital information, lack of access to data for measuring care transition quality, and the absence of patient/caregiver satisfaction assessments to inform service enhancements. Additionally, organizations require support in managing change.
This need for improvement, coupled with the aspiration for a patient-centered learning health system (LHS), motivated the Institut national d'excellence en santé et services sociaux (INESSS), the Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS CA), and the research team to collaborate on adapting a proven continuous improvement program: the CoMPAS+ MNCD Program.
The Program will involve reflecting on best practices and identifying local challenges within participating Family Medicine Groups (FMGs) to propose and implement solutions. The CONSTELLATIONS Living Lab project has been tasked with co-developing, implementing, and evaluating the Program's impact on care transitions over two years. These findings will inform decision-makers and stakeholders about the Program's adaptability to the Chaudière-Appalaches region, guiding local and provincial decision-makers on healthcare system improvements and emphasizing the importance of supporting an LHS.
Eligibility
Primary outcome measure(s)
- Perceived quality of care: The variation in the Physician Enabling Skills Questionnaire (PESQ) scores. — Between T=0 and T=15 months with an intermediate measure at T=9 months.
The PESQ is a 34-item scale with six subscales, used to assess the ability of family physicians to empower their patients. Total scores range from 34 to 170, with higher scores indicating greater patient autonomy facilitation. The PESQ aligns with recommendations from systematic reviews for improving care transitions, emphasizing patient and caregiver participation, provider empowerment, and decision-maker support for incremental change. This questionnaire demonstrates adequate internal consistency and has been validated in French within Quebec. Pre-Post Comparison: Scores will be compared to identify statistically significant changes from the patient's perspective. A variation of 6.8 PESQ points between T=0 and T=15 months will be considered significant. Subgroup Comparisons: Scores will be analyzed across subgroups based on recruitment points (ED, HCT, FMG) to explore any differences in perceived care quality related to the point of initial contact.
Trial sites (1)
| Facility | City | Region | Status |
|---|---|---|---|
| Patrick Archambault | Québec | Quebec | Recruiting |
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This page summarises publicly available registry data for informational purposes — not medical advice. Eligibility is determined by each study team; patients should discuss participation with their clinician.
View NCT06608589 on ClinicalTrials.gov ↗ ← All trials in Canada