Virtual Nurse and Social Worker Palliative Care Team to Improve Quality of Life in Veterans With Heart Failure or COPD

Starting soon · Not applicable

Conditions studied: Heart Failure, Pulmonary Disease, Chronic Obstructive, Interstitial Lung Disease

In brief

Many Veterans living with heart failure or chronic obstructive pulmonary disease (COPD) experience significant symptoms - such as breathlessness, fatigue, depression, and anxiety -that reduce their quality of life. Despite how common these symptoms are, they are often not adequately addressed in routine care. This study tests whether a virtual team of a nurse and social worker can improve quality of life, depression, anxiety, and other patient-reported outcomes for Veterans with heart failure or COPD who are at high risk of hospitalization or death. The nurse helps Veterans manage their most bothersome symptoms using a structured approach, and the social worker provides brief counseling to address emotional and psychological concerns. Both work closely with the Veteran's primary care provider and palliative care clinician to coordinate additional care as needed. The study also examines whether enhanced implementation support helps VA sites adopt the program more successfully compared to standard implementation support.

Key facts

Study ID

NCT07714252

Run by

VA Office of Research and Development

People needed

420

Starts

2026-08-01

Expected to finish

2030-09-30

Last updated by the study team

2026-07-20

Who can join

Age: 18 and older. Sex: any. Healthy volunteers: not accepted.

You may qualify if…

• At least one primary care encounter in the past year, identified by primary care stop codes (301, 322, 323, 342, 348, 350, 704)
• Diagnosed with heart failure, COPD, or interstitial lung disease, defined as 2 or more outpatient or community care provider visit encounters with a qualifying ICD code at least 30 days apart, or 1 inpatient hospitalization with a qualifying ICD code as the primary discharge diagnosis, within the past year
• Care Assessment Need (CAN) 3.0 score ≥ 90 at some point in the prior 6 months
• Poor self-reported quality of life, defined as a FACT-G score ≤ 70 at screening
• Consistent access to a telephone

You may not qualify if…

• Dementia diagnosis (any inpatient, outpatient, or community care encounter with qualifying ICD code in the prior 3 years)
• Cancer diagnosis (2 or more outpatient or community care provider visit encounters, or 1inpatient primary discharge diagnosis, with a qualifying ICD code in the prior 1 year)
• Current substance misuse (at least 1 inpatient or outpatient encounter with a qualifying substance/alcohol ICD code or stop code in the prior 6 months)
• Currently receiving palliative care (at least 1 inpatient or outpatient encounter with palliative care stop codes 351 or 353 in the prior 1 year)

Where it is running

• Phoenix VA Health Care System, Phoenix, AZ — Phoenix, Arizona, United States
• VA Long Beach Healthcare System, Long Beach, CA — Long Beach, California, United States
• Rocky Mountain Regional VA Medical Center, Aurora, CO — Aurora, Colorado, United States
• Overton Brooks VA Medical Center, Shreveport, LA — Shreveport, Louisiana, United States
• Lebanon VA Medical Center, Lebanon, PA — Lebanon, Pennsylvania, United States
• Providence VA Medical Center, Providence, RI — Providence, Rhode Island, United States
• Cheyenne VA Medical, Cheyenne, WY — Cheyenne, Wyoming, United States

Full record on ClinicalTrials.gov

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