The following is a summary of “Implementation Challenges for a Multisite Advance Care Planning Pragmatic Trial: Lessons Learned,” published in the August 2023 issue of Pain and Symptom Management by Sudore et al.

Researchers identified crucial system-level activities for implementing Advance Care Planning (ACP) interventions in a cluster-randomized pragmatic trial. Patients with severe medical conditions were identified from 50 primary care clinics spanning three health systems affiliated with the University of California. This identification process was conducted using a verified algorithm. If patients did not have documented Advance Care Planning (ACP) within the past 3 years, they met the criteria for an intervention: (Arm 1) the provision of an advance directive (AD); (Arm 2) AD + PREPAREforYourCare.org; (Arm 3) AD + PREPARE + outreach by a lay health navigator. Initiated by a scheduled consultation, they dispatched and transmitted interventions via automated electronic health record (EHR) messaging. They collaborated with patients/caregivers, clinicians, payors, and national/health system leader advisors. 

Investigators are currently concluding the collection of 24-month follow-up data. They employed the Consolidated Framework for Implementation Research (CFIR) and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to monitor secular trends and implementation endeavors in a medical context. Necessary multisite, system-wide activities: Acquiring leadership, legal/privacy, and electronic health record (EHR) authorizations; establishing uniform advance care planning (ACP) documentation; 3) delivering educational programs to healthcare providers; verifying the accuracy of an automated algorithm for identifying serious illnesses; establishing consistent ACP messaging with the collaboration of more than 100 essential advisors; monitoring ongoing trends in the healthcare landscape, such as the impact of COVID-19; and establishing standardized ACP workflows, including the digitization of advance directives (ADs). 

Out of 8,707 individuals diagnosed with a severe medical condition, 6,883 met the criteria for receiving medical intervention. Across all arms, 99% of participants received the mailed intervention, 78.3% had an active patient portal (64.2% opened the intervention), and 90.5% of patients in arm three (n = 2243) received navigator outreach. Executing a multisite healthcare system-wide Advance Care Planning (ACP) program and pragmatic trial, utilizing automated Electronic Health Record (EHR)-based cohort identification and intervention delivery, necessitates substantial involvement from a diverse group of key advisors, as well as the establishment of standardized protocols and ongoing monitoring. These activities offer direction for the execution of additional extensive, population-focused Advance Care Planning (ACP) initiatives.

Source: sciencedirect.com/science/article/abs/pii/S0885392423004840