Implementing Advance Care Planning in a Range of Primary Care Practices: Adapting the Serious Illness Care Program for a Comparative Effectiveness Trial (GP797)

• Published in: Journal of pain and symptom management Vol. 60; no. 1; pp. 302 - 303
• Main Authors: Nowels, David, Izumi, Seiko, Totten, Annette
• Format: Journal Article
• Language: English
• Published: Madison Elsevier Inc 01.07.2020; Elsevier Limited
• Subjects: Adaptation; Advance directives; Anesthesia; Care plans; Charges; Environmental aspects; Fidelity; Flexibility; Health care; Illnesses; Implementation; Interagency collaboration; Interdisciplinary aspects; Leadership; Pain Medicine; Palliative care; Primary care; Standardization; Teams
• ISSN: 0885-3924; 1873-6513
• DOI: 10.1016/j.jpainsymman.2020.04.224

Objectives Identify implementation and adaptation issues specific to advance care planning in primary care Consider application of approaches to both the implementation and study of ACP in different settings. Importance. Advance care planning (ACP) is an important foundational step in consideration of palliative care by clinicians and patients and in maximizing wellbeing of patients with serious illnesses. To realize this potential ACP needs to be routine in settings where these patients receive care. Objective(s). 1) Describe the theoretical basis and practical issues in adapting the Serious Illness Care Program (SICP) in 42 primary care practices. 2) Assess modifications required local contexts. 3) Describe barriers to ACP implementation in primary care and demonstrate strategies used to overcome them. Method(s). We adapted SICP and developed training appropriate for two models (clinician-focused and team-based) that are the subject of a cluster randomized trial. For the team arm, training was modified based on a model of interprofessional collaboration. Practice facilitators provided training and integrated ACP into workflows. Data from interviews, training evaluations, and practice progress reports were analyzed to describe adaptation for the trial, modification for practice environments and fidelity assurance. Implementation frameworks and modification and adaption models for were used to inform data collection and analysis. Results. Three practices were replaced before training due to leadership and administrative issues. Practices completed training, implemented ACP and referred patients to the research study. Needed modifications varied across practices and the models. Training and workflow challenges were greatest in practices implementing the team model. Practices without population health systems where challenged to identify appropriate patients for ACP. Documentation for follow-up and billing were challenging across the models. Conclusion(s). Attention to diverse structural and environmental factors is required to balance fidelity and adaptation of ACP in primary care practices, particularly as part of a research trial which requires balancing standardization and flexibility. Impact. Our experience can inform design and conduct of future trials that strive to produce knowledge about both comparative effectiveness and implementation in primary care.