Conditions Associated with the Pragmatic Implementation of an Advance Care Planning Intervention in Nursing Homes (RP125)

Outcomes 1. Discuss the conditions associated with the successful pragmatic implementation of an advance care planning intervention in the nursing home. 2. Describe the use of Coincidence Analysis, an innovative mathematical, cross-case approach that draws upon Boolean algebra, logic, and set theory to identify the bundles of conditions that consistently distinguish high performing sites from lower performing sites.Key MessageUsing a novel analytical approach, we identified the conditions associated with the successful pragmatic implementation of an ACP intervention across 64 nursing homes. Leadership stability and staff engagement were key conditions, as were greater opportunities for improvement and a more manageable caseload, highlighting the complexity of implementation.ImportanceThe "Aligning Patient Preferences – a Role Offering Alzheimer's patients, Caregivers, and Healthcare Providers Education and Support" (APPROACHES) project was a pragmatic trial designed to test and evaluate a staff-led advance care planning (ACP) intervention for residents with ADRD.(1) Understanding the conditions associated with successfully implementing interventions in nursing homes is of importance to researchers, policy makers, and health system leaders encouraging uptake of evidence-based programs.Objective(s)To identify the conditions associated with successful implementation of APPROACHES in the NH setting.Scientific Methods UtilizedAPPROACHES was delivered by specially trained ACP Specialists who were employed by the facility and supported by a corporate lead between September 1, 2022 - August 31, 2023. Our primary outcome measure was the number of residents with documentation of an ACP encounter in the EHR divided by the total number of beds in the NH. We used Coincidence Analysis, an innovative mathematical, cross-case approach that draws upon Boolean algebra, logic, and set theory to identify the bundles of conditions relevant to implementation that distinguished high from lower performing sites (2). Successful implementation was defined as >75% of residents had documented ACP encounters in their chart at the end of the intervention period.ResultsTwenty of 64 sites (31%) successfully implemented the intervention. Our Coincidence Analysis identified 2 solutions linked with successful implementation: a) no executive director turnover and site participation in monthly peer support calls; and b) higher baseline hospitalization rate (3.96 – 7.2 per 1000 resident days) and small number of certified beds.Conclusion(s)Leadership stability and engagement with peers were drivers of successful implementation. Greater improvement opportunities and a more manageable caseload may also help explain successful implementation.ImpactThese findings contribute to our understanding of conditions for successful implementation of ACP interventions in the nursing home setting and highlight the complexity of implementing evidence-based interventions in this setting.KeywordsAdvanced care planning/shared decision making/Educational, training and supervision 1. Discuss the conditions associated with the successful pragmatic implementation of an advance care planning intervention in the nursing home. 2. Describe the use of Coincidence Analysis, an innovative mathematical, cross-case approach that draws upon Boolean algebra, logic, and set theory to identify the bundles of conditions that consistently distinguish high performing sites from lower performing sites. Using a novel analytical approach, we identified the conditions associated with the successful pragmatic implementation of an ACP intervention across 64 nursing homes. Leadership stability and staff engagement were key conditions, as were greater opportunities for improvement and a more manageable caseload, highlighting the complexity of implementation. The "Aligning Patient Preferences – a Role Offering Alzheimer's patients, Caregivers, and Healthcare Providers Education and Support" (APPROACHES) project was a pragmatic trial designed to test and evaluate a staff-led advance care planning (ACP) intervention for residents with ADRD.(1) Understanding the conditions associated with successfully implementing interventions in nursing homes is of importance to researchers, policy makers, and health system leaders encouraging uptake of evidence-based programs. To identify the conditions associated with successful implementation of APPROACHES in the NH setting. APPROACHES was delivered by specially trained ACP Specialists who were employed by the facility and supported by a corporate lead between September 1, 2022 - August 31, 2023. Our primary outcome measure was the number of residents with documentation of an ACP encounter in the EHR divided by the total number of beds in the NH. We used Coincidence Analysis, an innovative mathematical, cross-case approach that draws upon Boolean algebra, logic, and set theory to identify the bundles of conditions relevant to implementation that distinguished high from lower performing sites (2). Successful implementation was defined as >75% of residents had documented ACP encounters in their chart at the end of the intervention period. Twenty of 64 sites (31%) successfully implemented the intervention. Our Coincidence Analysis identified 2 solutions linked with successful implementation: a) no executive director turnover and site participation in monthly peer support calls; and b) higher baseline hospitalization rate (3.96 – 7.2 per 1000 resident days) and small number of certified beds. Leadership stability and engagement with peers were drivers of successful implementation. Greater improvement opportunities and a more manageable caseload may also help explain successful implementation.