ABSTRACT
BackgroundFew trials on advance care planning (ACP) have investigated the clinical effect on care consistency with care preferences (3CP) in the nursing home (NH) setting.MethodsBEVOR is a multi-centre, cluster-randomized controlled trial aimed to improve 3CP in NH residents (09/2019–02/2023). A total of 44 NHs from 4 German regions were randomized either to the control group (n=24) or the intervention group (n=24). The complex ACP intervention comprised the offer to lead ACP conversations with qualified facilitators on the individual (resident) level and offers for organizational development and staff education on the institutional (NH) level. Educational ACP modules were offered to emergency medical services, hospitals and other regional players relevant for these residents' medical care.After a run-in phase of the intervention, which was extended due to the Covid19-pandemic from originally 9 to (up to) 18 months, the observation period was 12 months from September 2021 to August 2022. Primary outcome was defined as hospitalization rate, understood as a surrogate parameter for 3CP, collected as anonymous data from all residents of the participating NHs. Main secondary outcome is 3CP, taken from a subset of 892 residents (20.5%) who gave informed consent. To measure 3CP, treatment decisions in potentially life-threatening events (‘care delivered') were identified retrospectively every 3 months from the NH records. Correspondingly, ‘care preferences' were assessed retrospectively, integrating data from residents' files and interviews with residents, proxies and nurses, also taking into account the effected level of shared decision making. Analysis of the primary outcome follows the intention-to-treat principle.ResultsThe main outcomes will be available by the time of the acp-i conference.ConclusionResults of the BEVOR trial will give insights into possible clinical effects of a complex regional ACP intervention.
ABSTRACT
BackgroundImplementation of a comprehensive advance care planning (ACP) intervention package offered to nursing homes (NH) as part of a cluster-randomized trial (BEVOR) during the Covid-19 pandemic led to intensified efforts of the study team comprising ACP facilitators and trainers to improve take-up and adherence to intervention schedules. Analyzing institution-level barriers as well as enabling factors from the perspective of the study team aims to provide insights how to strengthen capacities of researchers and practitioners working towards organizational development and systems change.MethodsA qualitative approach drawing on data from documents containing guided structured self-reflection of the study team and notes from moderated case discussions with high-expertise ACP trainers and an professional organisation developer, using the framework analysis method to derive themes and compare patterns across the NHs participating in the study, pertaining to 3 experiential spaces (‘person' ‘ACP facilitator' and ‘NH').ResultsThe structured self-reflection and intensive exchange supported the ability of the study team to deal with challenges during implementation. Preliminary results indicate emotional challenges e.g. feelings of rejection when access to NH staff and time resources is blocked, and stress due to time pressure (personal). Investment of single NH staff members to remove barriers such as mistrust or fear encapsulated feelings of encouragement (personal, ACP facilitator). Institution-level enablers and barriers (NH), such as the extent of commitment and initiative of NH staff and management or treating physicians' investment, exposed a high temporal dynamic and unpredictability, e.g. sudden withdrawal or pick-up of commitment following changes in NH management.ConclusionIn depth-reflection and analysis, contextualizing experiences and practices, is a valuable resource during the ACP implementation to enhance intervention uptake in a trial or project context. Importantly, its collective character can help to refocus on the mutual goal of creating change as core driver and motivation for the work.