SHARING Choices: Lessons Learned from a Primary-Care Focused Advance Care Planning Intervention

Area of Science:

• Implementation science in healthcare delivery.
• Pragmatic clinical trials in primary care settings.
• Geriatric medicine and palliative care.

Background:

• Scaling advance care planning (ACP) interventions in primary care remains a challenge.
• Existing best practices for large-scale ACP delivery are lacking.
• Previous efforts have not adequately included older adults with Alzheimer's Disease and Related Dementias (ADRD).

Purpose of the Study:

• To describe the implementation process of the SHARING Choices multicomponent intervention in primary care practices.
• To assess fidelity to the planned implementation of ACP.
• To identify lessons learned from deploying ACP at scale within two health systems.

Main Methods:

• A cluster-randomized pragmatic trial involving 19 primary care practices randomized to the intervention arm.
• Engagement with organizational and clinic-level partners for embedding the intervention.
• Tracking patient outreach, ACP conversation rates, duration, family involvement, and patient demographics including ADRD.

Main Results:

• ACP facilitators made 17,931 outreach attempts, resulting in 1215 ACP conversations.
• Most conversations (94.8%) were under 45 minutes, with family involvement in only 13.1%.
• Patients with ADRD were a small proportion of those engaged; adaptations included remote modalities and aligning with Medicare Annual Wellness Visits.

Conclusions:

• Adaptable study designs are crucial for successful implementation of ACP in primary care.
• Co-designing workflow adaptations with practice staff is essential.
• Tailoring implementation processes to health system needs and goals enhances effectiveness.