Tests tiered palliative care that changes as needs change in heart failure or cancer
Tests tiered palliative care support for adults with advanced heart failure or cancer.
Plain-language title generated from the registry record
Registry title: Tier Palliative Care For Patients With Advanced Heart Failure or Cancer
Key facts
- Where
- Astoria and New York, United StatesSee the 5 sites
Where in United States
- Mount Sinai QueensAstoria, United StatesTaking people
- Mount Sinai DowntownNew York, United StatesTaking people
- Mount Sinai HospitalNew York, United StatesTaking people
- Mount Sinai MorningsideNew York, United StatesTaking people
- Mount Sinai WestNew York, United StatesTaking people
Questions to ask the study team
- How often do I need to come in, and for how long each time?
- Are travel costs paid?
- Can I keep my own doctor?
- What happens if I want to stop?
Trial details
- Who runs it
- Icahn School of Medicine at Mount Sinai
- Trial code
- NCT07391956
- Record updated
- 14 September 2026
- Original description
TIER-PC is an adaptive model of delivering palliative care that provides the right level of care to the right patients at the right time. It represents an adaption of the Mount Sinai PALLIATIVE CARE AT HOME (PC@H) program, which delivers home-based palliative care. TIER-PC increases the number and intensity of disciplines added to the patient's care team as their symptoms worsen and function declines. In Tier 1, patients who are able to care for themselves and no/mild symptoms receive a community health worker (CHW) trained to elicit illness understanding in a culturally competent way. In Tier 2, for patients with poorer function and mild symptoms, a social worker (SW), trained in serious illness communication, joins the CHW to further elicit patients' goals and prognostic understanding while communicating symptom needs to their primary clinician. In Tier 3, as function decreases and symptoms increase, an advance practice nurse (APN) joins the CHW and SW to manage complex symptoms. Finally, in Tier 4, for those older adults with the poorest function and most complex symptoms, a physician joins the team to ensure that the most complex needs (e.g., end-of-life treatment preferences and multifaceted symptom control) are met. The CHW follows patients longitudinally across all tiers and re-allocates them to the appropriate tier based on their evolving needs.Read full original descriptionShow less
TIER-PALLIATIVE CARE: A Population-based Care Delivery Model to Match Evolving Patient Needs and Palliative Care Services for Community-based Patients With Heart Failure or Cancer
TIER-PC is an adaptive model of delivering palliative care that provides the right level of care to the right patients at the right time. It represents an adaption of the Mount Sinai PALLIATIVE CARE AT HOME (PC@H) program, which delivers home-based palliative care. TIER-PC increases the number and intensity of disciplines added to the patient's care team as their symptoms worsen and function declines. In Tier 1, patients who are able to care for themselves and no/mild symptoms receive a community health worker (CHW) trained to elicit illness understanding in a culturally competent way. In Tier 2, for patients with poorer function and mild symptoms, a social worker (SW), trained in serious illness communication, joins the CHW to further elicit patients' goals and prognostic understanding while communicating symptom needs to their primary clinician. In Tier 3, as function decreases and symptoms increase, an advance practice nurse (APN) joins the CHW and SW to manage complex symptoms. Finally, in Tier 4, for those older adults with the poorest function and most complex symptoms, a physician joins the team to ensure that the most complex needs (e.g., end-of-life treatment preferences and multifaceted symptom control) are met. The CHW follows patients longitudinally across all tiers and re-allocates them to the appropriate tier based on their evolving needs.
Inclusion: Advanced Heart Failure (HF) with two HF-related hospitalizations within the last 12 months or; Advanced lung or non-colorectal gastrointestinal cancer (pancreatic, gastric, hepatobiliary, small bowel, esophageal) or tripe negative breast cancer with one hospitalization within the last 6 months; KPS > or = 50% (ECOG 0, 1 or 2); > 2 outpatient MSHS visits in prior 12 months; Manhattan or Queens residence; Capacity to provide informed consent; English or Spanish fluency; > or = 18 years of age.
Exclusion: Previous receipt of a ventricular assist device or previous heart transplantation; Receiving hospice care prior to study enrollment or enrolled in another study of a palliative care patient/caregiver intervention; Diagnoses of both cancer and advanced HF; Lung cancer with a driver mutation (e.g., EGFR) that confers a favorable prognosis and does not follow typical trajectory; Patients with > 1 visit to Outpatient Supportive Oncology/Cardiology visit; Patients with last visit to Outpatient Supportive Oncology/Cardiology < 3 months ago; Living in a facility (subacute rehab, long-term care facility, hospice facility or residence); Callahan 6-Item Cognitive Screening score ≤3.