Goal attainment
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GAS score will be higher in the intervention arm compared to the control arm at 6-months; proportion of participants who report maintaining or improving in the top priority goal area will be higher in the intervention arm than the control arm at 6-months
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Goal attainment scaling score [53] obtained from a structured interview; proportion of participants who report maintaining or improving in their top priority goal area
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T6, T12
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Linear regression for continuous variables; logistical regression for categorical variables
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Self-efficacy
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Higher self-efficacy, quality of life, optimal aging, social support, access, comprehensiveness, patient empowerment, patient-centeredness, and satisfaction of care and lower caregiver strain, hospital admissions, and emergency room visits will be reported in the intervention arm compared to the control arm at 6-months
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Self-efficacy for managing chronic disease [55]; self-report
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T0, T6, T12
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Quality of life
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EQ5D-5L [56]; self-report
|
T0, T6, T12
|
Optimal aging
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Single-item optimal aging question from the Canadian Longitudinal Study on Aging [57]; self-report
|
T0, T6, T12
|
Social support
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DUKE social support index [58]; self-report
|
T0, T6, T12
|
Access
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CIHI common indicators; self-report [59]
|
T0, T6, T12
|
Comprehensiveness of care
|
T0, T6, T12
|
Patient empowerment
|
T0, T6, T12
|
Patient-centeredness
|
T0, T6, T12
|
Caregiver strain
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4-item Zarit screen [60]; self-report
|
T0, T6, T12
|
Satisfaction with care
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Single item, satisfaction rated from 1 to 10; self-report
|
T0, T6, T12
|
Hospitalizations and emergency room visits
|
EMR abstraction
|
T0, T6, T12
|