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

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Implementing advance care planning (ACP) pragmatic trials requires significant system-level coordination. Key activities include leadership engagement, EHR integration, and standardized workflows for effective patient intervention delivery.

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Area of Science:

  • Implementation Science
  • Health Services Research
  • Gerontology

Background:

  • Pragmatic trials for advance care planning (ACP) are essential for improving patient care.
  • Existing systems often lack robust mechanisms for identifying eligible patients and delivering ACP interventions effectively.
  • The need for system-level strategies to integrate ACP into routine clinical practice is critical.

Purpose of the Study:

  • To determine essential system-level activities for implementing ACP interventions within a large, multisite pragmatic trial.
  • To evaluate the feasibility and reach of automated, EHR-triggered ACP interventions across diverse patient populations.
  • To identify best practices for engaging stakeholders and standardizing processes in large-scale ACP implementation.

Main Methods:

  • A cluster-randomized pragmatic trial involving 50 primary care clinics across three health systems.
  • Automated identification of patients with serious illness using a validated algorithm within the electronic health record (EHR).
  • Delivery of tiered ACP interventions (advance directive, online resources, navigator outreach) triggered by patient appointments.
  • Utilized the Consolidated Framework for Implementation Research (CFIR) and RE-AIM frameworks for evaluation.

Main Results:

  • Multisite implementation required extensive leadership, legal, and EHR approvals, alongside standardized documentation and clinician education.
  • Automated identification successfully flagged 8707 patients with serious illness, with 6883 eligible for intervention.
  • High intervention reach was achieved: 99% received mailed materials, 64.2% of those with patient portal access opened interventions, and 90.5% in the navigator arm received outreach.

Conclusions:

  • Implementing a multisite, health system-wide ACP program necessitates robust multidisciplinary engagement, standardization, and monitoring.
  • Automated EHR-based identification and intervention delivery are feasible for large-scale ACP efforts.
  • These findings offer a roadmap for other organizations aiming to implement population-based ACP initiatives.