Implementation Challenges for a Multisite Advance Care Planning Pragmatic Trial: Lessons Learned

Rebecca L Sudore; Anne M Walling; Lisa Gibbs; Maryam Rahimi; Neil S Wenger; UC Health Care Planning Study Team

doi:10.1016/j.jpainsymman.2023.04.022

Implementation Challenges for a Multisite Advance Care Planning Pragmatic Trial: Lessons Learned

J Pain Symptom Manage. 2023 Aug;66(2):e265-e273. doi: 10.1016/j.jpainsymman.2023.04.022. Epub 2023 Apr 23.

Authors

Rebecca L Sudore¹, Anne M Walling², Lisa Gibbs³, Maryam Rahimi⁴, Neil S Wenger⁵; UC Health Care Planning Study Team

Affiliations

¹ Department of Medicine (R.L.S.), University of California, San Francisco, California; San Francisco VA Medical Center (R.L.S), San Francisco, California.
² Department of Medicine (A.M.W., N.S.W.), University of California, Los Angeles, California; VA Greater Los Angeles Health System (A.M.W.), Los Angeles, California. Electronic address: awalling@mednet.ucla.edu.
³ Division of Geriatric Medicine and Gerontology (L.G.), Department of Family Medicine, University of California, Irvine, California.
⁴ Division of General Internal Medicine and Primary Care (M.R.), Department of Medicine, University of California, Irvine, California.
⁵ Department of Medicine (A.M.W., N.S.W.), University of California, Los Angeles, California.

Abstract

Background/problem: Advance care planning (ACP) pragmatic trials are needed.

Proposed solution: We determined key system-level activities to implement ACP interventions for a cluster-randomized pragmatic trial. We identified patients with serious illness from 50 primary care clinics across three University of California health systems using a validated algorithm. If patients lacked documented ACP within the last 3 years, they were eligible for an intervention: (Arm 1) an advance directive (AD); (Arm 2) AD + PREPAREforYourCare.org; (Arm 3) AD + PREPARE + lay health navigator outreach. Triggered by an appointment, we mailed and sent interventions through automated electronic health record (EHR) messaging. We collaborated with patients/caregivers, clinicians, payors, and national/health system leader advisors. We are currently finalizing 24 months follow-up data.

Outcomes/methods: We used the Consolidated Framework for Implementation Research (CFIR) and Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to track secular trends and implementation efforts.

Key message/results: Required multisite, system-level activities: 1) obtaining leadership, legal/privacy, and EHR approvals; 2) standardizing ACP documentation; 3) providing clinician education; 3) validating an automated serious illness identification algorithm; 4) standardizing ACP messaging with input from over 100 key advisors; 5) monitoring secular trends (e.g., COVID); and 6) standardizing ACP workflows (e.g., scanned ADs). Of 8707 patients with serious illness, 6883 were eligible for an intervention. Across all arms, 99% received the mailed intervention, 78.3% had an active patient portal (64.2% opened intervention), and 90.5% of arm three patients (n = 2243) received navigator outreach.

Lessons learned: Implementing a multisite health system-wide ACP program and pragmatic trial, with automated EHR-based cohort identification and intervention delivery, requires a high level of multidisciplinary key advisor engagement, standardization, and monitoring. These activities provide guidance for the implementation of other large-scale, population-based ACP efforts.

Keywords: Advance care planning; implementation science; pragmatic trial.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Advance Care Planning*
Advance Directives
COVID-19*
Documentation
Humans

Grants and funding

K24 AG054415/AG/NIA NIH HHS/United States