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Virtual Nurse and Social Worker Palliative Care for Veterans with Heart Failure or COPD

This study is testing if a virtual team of a nurse and social worker can improve the quality of life for Veterans with heart failure (a condition where the heart can't pump enough blood) or chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it hard to breathe). Many Veterans with these conditions experience symptoms like breathlessness, fatigue, depression, and anxiety. The virtual team will provide direct care by phone or video, with the nurse helping manage symptoms and the social worker offering counseling. The study aims to see if this approach improves overall quality of life, depression, and anxiety. You might be able to join if you are a Veteran aged 18 or older, have had a primary care visit in the last year, and have been diagnosed with heart failure, COPD, or interstitial lung disease (a group of lung diseases that cause scarring of lung tissue). The study is currently recruiting 420 participants.

Study design
This is an interventional study with a planned enrollment of 420 participants. It compares a virtual nurse and social worker palliative care team with enhanced or standard implementation support.
What's involved
Your quality of life will be assessed every 6 months from before the study starts through a sustainment period of up to approximately 30 months. The main comparison of effectiveness will be at the end of your intervention period, which is about 4-6 months after you join.
Compensation
Not stated in the trial record.
Follow-up
Your health-related quality of life will be assessed every 6 months from pre-implementation through sustainment, which can be up to approximately 30 months.

AI-generated from the public study record. Only the study team can confirm whether you're eligible — confirm details with them before making decisions.

NCT07714252

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

Not Yet Recruiting
NAAges 18+InterventionalHealth services
VA Office of Research and Development
~420 participants
Updated 2026-07-20 on ClinicalTrials.gov
What's tested:Virtual Nurse and Social Worker Palliative Care TeamEnhanced Implementation SupportStandard Implementation Support

At a glance

Recruiting sites
0 of 7 listed sites are recruiting right now
RecruitingSuspended, closed, or not yet open
What they're measuring
Health-Related Quality of Life - Functional Assessment of Chronic Illness Therapy-General (FACT-G) Total Score
Measured over 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)

Conditions

Heart Failure
Pulmonary Disease, Chronic Obstructive
Interstitial Lung Disease

Explore related trials

Chronic Obstructive Pulmonary DiseaseHeart FailureInterstitial Lung Disease

Where it's being run

7 sites across 7 states
Arizona1
California1
Colorado1
Louisiana1
Pennsylvania1
Rhode Island1
Wyoming1

Study leadership

  • David Bekelman, MD MPH · PRINCIPAL_INVESTIGATOR · Rocky Mountain Regional VA Medical Center, Aurora, CO

Who to contact

David Bekelman, MD MPH
[email protected]
(720) 857-2809
Email the study team

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Do you actually qualify for this trial?

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Eligibility criteria

Inclusion

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

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)

What this trial measures

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

    The FACT-G is a 27-item Veteran-reported measure of health-related quality of life across four domains: physical, social/family, emotional, and functional well-being. Total scores range from 0 to 108, with higher scores indicating better quality of life. A 4-point difference represents the minimal clinically important difference in this population.