The TLC Model of Palliative Care in the Elderly: Preliminary Application in the Assisted Living Setting

Mehr makes some excellent points in his letter regarding the limitations of our initial evaluation of the TLC model.

Our primary goal in conducting the project was to characterize the most pressing unmet palliative care needs of the assisted living population, to better inform our then-developing TLC model. A second goal was to pilot test a limited scope intervention grounded in aspects of the TLC model. We are currently completing final analyses to determine the impact of the intervention on subject outcomes, and will submit them for publication in the near future. However, preliminary results suggest that, consistent with Mehr's comments, some changes in our intervention approach will likely be required to optimize its impact, and we have already begun planning future research with such modifications in mind.

For example, as Mehr correctly points out, non-physician team members could deliver many aspects of our intervention. Because our initial project was primarily funded by a small career development grant, we did not have the resources to assemble a multidisciplinary team. However, we are currently developing a more ambitious proposal for a better-funded, "next iteration" intervention that will include the Team-oriented aspect of the model.

As Mehr also notes, the intensity of intervention influences uptake of recommendations. Our preliminary results do in fact suggest that the intensity of our intervention may need to be increased in order to achieve adequate levels of uptake, but probably only for certain types of recommendations. For example, for recommendations regarding completion of advance directives, letters to the patient, involved family members, and primary provider were fairly effective in achieving uptake. By contrast, for recommendations regarding falls and fall-related injury prevention, we found letters alone seldom resulted in uptake.

To account for these findings, we are planning our future iteration of the intervention to include a range of intervention intensities, appropriately matched to the palliative recommendation at hand. In regard to advance directive recommendations, for example, the need for additional reinforcement is fairly minimal and will likely entail simple measures such as follow-up phone calls. By contrast, for fall-related recommendations, we will need a more comprehensive approach. This will include an approach to communicating recommendations to subjects and their family members that is more firmly grounded in health behavior change theory and explicitly accounts for important mediators of health behavior such as self-efficacy. It will also include an expanded role for facility staff and non-physician professionals (e.g. physical therapists) and on- site balance and gait training classes as a way of overcoming logistical barriers like having to rely on insurance approval of non-“acute need” physical therapy referrals.

We must take issue with Mehr's claim that our pilot intervention did not address the Collaborative element of the TLC model. While it was perhaps unclear in our preliminary report, the vast majority of our study encounters were co-attended by informal caregivers (mostly adult children) for our subjects. Furthermore, discussions regarding unmet palliative care needs and prioritization of intervention involved not only the subject and intervention physician but also their informal caregiver(s) and, when indicated, facility staff and the subjects' primary provider. We plan to continue to employ this collaborative approach and expand on it where feasible in our follow-up projects.

Finally, in response to Mehr's concern about how our model can best be implemented, it is worth reiterating that we proposed the TLC model as a general framework within which a variety of specific interventions might be developed. While we plan to continue to pursue our assisted living facility-based line of inquiry, other elderly patient sub-populations (e.g. community-dwelling) and intervention settings (e.g. outpatient clinics) might also be targeted. Furthermore, a variety of approaches to intervention (e.g. conferences with all the stakeholders including the primary care provider) might also be explored. Each of these variations will of course come with strengths and limitations.

We are gratified to see this interest in and discussion of our work, and we look forward to an ongoing dialogue.

Competing interests:   None declared