Not Yet RecruitingNot Applicable

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

United States420 participantsStarted 2026-08-01

Plain-language summary

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.

Who can participate

Age range

18 Years

Sex

ALL

See this in plain English?

AI-rewrites the medical criteria so a patient or caregiver can understand them. Always confirm with the trial site.

Inclusion Criteria: * 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 Exclusion Criteria: * 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)

Questions worth asking your doctor

Bring these to your next appointment. They're a starting point for a shared conversation — not a sign you qualify or a recommendation to enrol.

1This trial uses a virtual nurse and social worker team rather than in-person care — given my current condition and how comfortable I am with video or phone visits, is this kind of remote palliative support something that could realistically work for my situation?
2The trial is focused on improving quality of life rather than treating the disease itself — can you help me understand how palliative care at this stage fits alongside whatever active treatment I'm already on for my heart failure or COPD?
3Since this trial hasn't started recruiting yet, how long might I realistically need to wait before I could even be considered, and is there anything I should be doing in the meantime to address my quality of life?
4The study is measuring quality of life using a specific scoring tool called the FACT-G — what does that actually assess, and do you think those are the areas where I'm struggling most right now?
5Given that this is a palliative care support trial rather than a drug or procedure study, are there other existing programs — like established palliative care or social work services through the VA — that I could access right now without waiting for this trial to open?

Generated to help you prepare — always confirm anything about your own eligibility and care with the study team and your doctor.

Questions for the trial coordinator

The trial coordinator is the person who runs the study day to day. These cover the practical side — logistics, costs, and what taking part would actually mean for your life. The study team confirms whether you meet the criteria; these are questions to ask, not a sign you qualify.

1What does taking part actually involve week to week — how many visits, where, and how long does each one take?
2What costs are covered by the study, and what might I have to pay for myself, including travel, parking, or time off work?
3What happens during screening, and what happens if the study team confirms I don't meet the criteria after those tests?
4Who pays for the scans, blood work, and other tests the trial requires — the study, my insurance, or me?
5How will being in the trial affect my regular care, and will my own doctor stay informed and involved?
6Can I leave the trial at any point if I change my mind, and what would happen to my care if I do?

A starting point for the conversation — always confirm anything about your own eligibility, costs, and care with the study team and your doctor.

What they're measuring

Health-Related Quality of Life - Functional Assessment of Chronic Illness Therapy-General (FACT-G) Total Score

Timeframe: Assessed every 6 months from pre-implementation through sustainment (up to approximately 30 months); primary effectiveness comparison at the end of each Veteran's intervention period (approximately 4-6 months after enrollment)

Trial details

NCT IDNCT07714252

SponsorVA Office of Research and Development

Sponsor typeFED

Study typeINTERVENTIONAL

Primary completion2029-12-31

Contact for this trial

David Bekelman, MD MPH

(720) 857-2809 david.bekelman@va.gov

View on ClinicalTrials.gov More Heart Failure trials