Resources for Resiliency (R4R) Advance Care Planning: A Pilot Study to Test a Trauma-Informed Care-adapted Advance Care Planning Intervention Among Affordable Housing Residents in Nashville
Phase: NA
Conditions: Advance Care Planning
Sponsor: Vanderbilt University

The R4R Advance Care Planning Pilot Study (R4RACP)
NCT06129149
11/7/2025

1 
A. Specific Aims and Hypothesis
Long-term objectives and goals. Vanderbilt University School of Nursing (VUSN) partnered with aand Urban
Housing Solutions (UHS) – the second largest provider of affordable housing in Nashville - are partners with the
long-term goal of reducing health disparities among medically-underserved UHS residents in Nashville. This
partnership is developing resiliency hubs that will provide essential services and support within a communal setting at
the housing facility. Within the context of this partnership, we are collecting preliminary data showing that UHS
residents lack information about and access to advance care planning (ACP), which specifies their healthcare wishes
during cognitive incapacitation or end-of-life, and nationwide, research shows significant disparities regarding ACP
participation among low-income populations. The short-term goal of the proposed work is to pilot test a single-arm,
pre-post intervention to assess the initial efficacy and implementation outcomes of a trauma-informed care (TIC)-
adapted ACP intervention to improve learning and communication for times of decisional incapacity among UHS
residents, within the context of a resiliency hub model. This is a necessary first step for developing a long-term
research portfolio dedicated to addressing ACP disparities and promoting equitable end-of-life planning among low-
income, medically-underserved populations. The PI is an early-stage, postdoctoral-level researcher and this work
would be the first opportunity to pilot this work as PI, in preparation for future studies of the efficacy and
implementation of this novel intervention with staff, resident peers, residents, and caregivers.
Specific aims:
Aim 1. Pilot test a TIC-adapted ACP intervention with UHS residents in an affordable housing-located
resiliency hub for initial efficacy, based on outcomes of ACP values/beliefs, processes (e.g., looking up ACP
information), and actions (e.g., advance directive completion, family conversations about life-sustaining
measures). We will enroll a cohort of UHS residents (n=30) to assess baseline ACP status, Adverse Childhood
Experiences, and previous death-related experiences and deliver an intervention that is sensitive to past trauma
following a novel standardized ACP checklist developed from a narrative synthesis of ACP conversation guides [1].
H1. We hypothesize the intervention will decrease misconceptions about ACP (ACP values/beliefs), increase ACP
processes, and increase ACP actions (e.g., advance directive completion, family conversations about life-sustaining
measures).
Aim 2. Assess intervention acceptability, appropriateness, and feasibility among residents and preliminary
barriers and facilitators to implementation. Anticipated barriers and facilitators may include identifying peers and
staff to facilitate ACP discussions; document management and retention; dedicating time and space to intervention
delivery vs. addressing critical social determinants of health (e.g., transportation, food, healthcare), and long-term
decisional support as ACP preferences change with life and health events. In addition to the residents completing a
brief implementation outcomes survey, we will hold audio-recorded 15-minute debriefs with residents following the
intervention to assess process concerns and barriers and facilitators. H2: We hypothesize that UHS residents (n=30)
will find the intervention to be acceptable, appropriate, and feasible.
B. Background and Significance
Urban Housing Solutions (UHS) a non-profit organization, is the second-largest affordable housing provider in
Nashville and provides housing for over 1,000 residents on a sliding scale (30% of income) [2]. VUSN has
partnered with UHS since 2012 and this experience has
shown that UHS residents have little access to preventative, 
community-based healthcare and continue to experience
other resource deficits (e.g., transportation, food, and
communication technology). To address this need for more
sustainable solutions to multiple and overlapping
insecurities, Dr. Christian Ketel and Dr. Kate Clouse from
VUSN, along with UHS, have created the Resources for
Resiliency (R4R) study to develop resiliency hubs within
communal settings at UHS properties. These hubs (Figure
1) will feature critical resources and referrals that residents
need in everyday life. ACP is a critical component of
comprehensive resiliency-hub model to facilitate timely,
patient-centered discussions on what matters most during
times of decisional incapacity for this disenfranchised
population. Within this context, through the support of the
two-year PROgRESS T32 program, Dr. Kimpel (PI of the
proposed work) currently is collecting critical preliminary
Figure 1. Resiliency hub model

 
 
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data about the prevalence of ACP completion and knowledge among UHS residents (n=200), as well as important 
potential factors that may influence ACP completion (Adverse Childhood Experiences). While this preliminary work 
will inform the initial development of the proposed ACP intervention, it does not include testing the intervention for 
initial efficacy and implementation outcomes of a pilot intervention in this setting, which is why this funding 
opportunity is a critical next step of this research. Through this pilot study, in collaboration with UHS, we will 
conduct essential preliminary research to develop this ACP intervention. This work is significant because we are 
directly targeting an important healthcare disparity that is often overlooked: the right to plan for times of cognitive 
incapacity. Research nationwide shows that adults with limited income are less likely to complete any ACP (26-33%) 
compared with those with high income [3, 4]. Optimal ACP is a life-long, iterative process of learning and 
communication about healthcare preferences for times of decisional incapacity for patients and caregivers. When 
equitably implemented, patients and families learn about life-sustaining care options (e.g., CPR), clarify values and 
preferences (e.g., Do Note Resuscitate), prepare for in-the-moment decision-making during health crises, and 
participate in formal and informal documentation and discussion [5]. Despite this aim, typical ACP, if it happens at 
all, consists of superficial discussions, incomplete documentation, and little awareness or attention to the possibility of 
triggering trauma from previous death-related experiences, leading to poorer patient, caregiver, and provider 
outcomes. ACP barriers for this population include the competing priorities of unmet basic needs, lack of ACP 
knowledge, limited social support, medical mistrust, and insufficiently trained clinical staff, which is why community-
based ACP is so essential to facilitate early and continued learning and education [6, 7]. Early intervention is even 
more crucial for this population given the profound, negative health and healthcare consequences from chronic stress 
(e.g., early mortality) [3, 4, 7-17]. While UHS has made important strides to facilitate service connections, the 
services available are insufficient to support ACP in the proposed population, which makes this a novel setting for 
ACP intervention [6, 18]. Based on the PI’s previous qualitative work and literature [6, 18-20], ACP is a stressful 
process and successful implementation with this population may depend on previous trauma (childhood experiences 
and previous death-related experiences). This work represents an innovative adaptation using principles of trauma-
informed care [21]. Additionally, to our knowledge, such adaptations have yet to be explored in this novel affordable 
housing context. This work is significant because it will inform a larger future study that has the potential to 
positively impact equitable, patient-centered, and timely healthcare. During and after a crisis, when ACP does not 
happen, caregivers and other social supports may experience additional decisional conflict, emotional distress, and 
prolonged grief [5]. Patients from disadvantaged background are likely to experience lower-quality end-of-life care, 
including unnecessary hospitalizations, little to no palliative care, and hospital deaths when home deaths are often 
preferred [22]. The overarching goal of this research is to positively impact patients with the dignity of choice and 
will support future studies that aim to reduce the harmful outcomes resulting from this disparity.
C. Preliminary Studies
During the summer of 2020, Dr. Kimpel 
conducted five qualitative interviews 
with Nashville affordable housing 
specialists to hone the approach for her 
dissertation study protocol and learn 
more about the population of interest. 
Following her dissertation, she identified 
that structural, life-stage, and social 
stressors and resources strongly 
influence individual stress responses and 
ACP motivation, which in turn affects 
ACP preferences and practices (Figure 
2). The findings also emphasized the 
importance of trust and a general history 
of disenfranchisement. This finding 
reinforced the plan to use trusted 
community partnerships, face-to-face study interactions to promote rapport, and emphasized the investigator’s 
reliance on participant expertise to fuel the proposed study. Resident illiteracy was also major finding from these 
interviews and influenced the choice of investigator-administered study instruments. This work informed variable 
selection for the ongoing R4R study (September 2023–June 2025): healthcare access and quality, resilience, coping, 
and adverse/positive childhood experiences. Dr. Kimpel is serving as a Co-Investigator on the R4R study and 
overseeing all study ACP measures. After piloting the R4R questionnaire with 15 residents of one of  UHS’s sites  
Figure 2. Conceptual framework of cumulative resources and stressors, individual 
stress responses, and advance care planning outcomes. 

 
 
3 
in September 2023, 8/15 (53%) stated they would be “very interested” in a center that provides “end-of-life planning” 
and 73.3 % (11/15) were “very interested” in a center that provides medical or legal planning. Although eight (53.3%) 
stated they had heard of ACP before, most respondents (13/15, 86.7%) had not completed an advance directive, only 
7/15 (46.7) had informally identified a healthcare decision-maker, 6/15 (40%) had discussed life-sustaining measures 
and quality of life with family, and only 3/15 (20%) had discussed ACP with their doctor. These numbers underscore 
the significant need for adaptive and early intervention to explore patient planning needs, carefully screen for 
trauma and adapt approach to trauma needs, and foster appropriate follow-up for patients. The R4R Study preliminary 
data and procedures will inform ongoing intervention development for this proposed study. 
D. Research Design and Methods  
D1. Design. We will implement a single-arm, pre-post intervention to test initial efficacy of the intervention (ACP 
values/beliefs, processes, and actions) with the population 
of interest (Aim 1) and assess implementation outcomes 
(barriers and facilitators, resident acceptability, 
appropriateness, and feasibility) in the affordable housing 
resiliency hub setting (Aim 2).  
D2. Intervention. The intervention will consist of a single 
one- to two-hour visit wherein the PI (Kimpel) will facilitate 
a flexible conversational approach with the resident (and, 
optionally, a healthcare decision-maker) in a quiet, private 
location in the resiliency hub. The conversation will follow 
a standardized process of ACP to assess each participant’s 
unique background with ACP, knowledge needs, explore 
values, preferences, and goals, and to identify readiness for 
ACP actions (e.g., AD completion) to evaluate initial 
knowledge. Over 34 ACP conversation guides have been 
developed as interventions, but all guides take different 
approaches that may not comprehensively address patient 
needs. To facilitate a comprehensive and flexible approach, 
the PI will create an ACP checklist that is derived from a 
narrative synthesis of the structure and content of the most 
prominent ACP conversation guides [1] The overall 
structure of the ACP checklist for this intervention is 
portrayed in Table 1. The innovative approach will 
include initial and ongoing adaptations of the checklist with 
TIC principles: safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, 
and choice, and cultural, historical, and gender issues [23-25]. Adverse Childhood Experiences and previous death-
related experiences assessed during baseline data collection will be used to tailor the discussion to carefully explore 
relevant history to assess resident ACP values, preferences, and goals. Participants will be offered the opportunity to 
complete an advance directive, but some participants may not be ready for this step, as follow-up questions may arise 
for additional family, friends, or provider discussion. Following each intervention session, the PI will hold a fifteen- 
to twenty-minute, audio-recorded discussion to review the intervention for possible adaptations to align it with TIC 
principles and barriers and facilitators (Aim 2). While peer support will not be used in this intervention, participants 
will be asked for suggestions of how to involve peers to facilitate the ACP process. 
D3. Eligibility. Inclusion criteria for enrollment in the intervention will include an adult (18+) residing in a UHS unit 
that does not have a completed advance directive and exclusion criteria include inability to provide informed consent 
or participate in the intervention due to cognitive, auditory, visual impairment or non-English language barrier.  
D4. Recruitment and enrollment. We will purposively sample from one of UHS’s properties. Participant selection 
will start with R4R study participants that communicated interest in future study participation and non-participants 
that were interested, but unable to participate in the study due to randomized selection. Residents will be contacted by 
phone, text, or door knocking depending on their communication preference and availability of contact information 
from the R4R study. If the individual does not answer the door, a letter and flyer will be left at the door with the 
contact information of the study team. We also will post study flyers in common spaces to advertise the study. To 
promote a diverse sample, we will stratify by age (1 are 18 to 39, 14 are 40 to 59, and 15  are 60+), 16-20 
identify as Black or African American, and 16-20 identify as male. If eligible (inclusion criteria are met, and no 
exclusion criteria are present), the PI or Key Study personnel (KSP) will set a time to meet in person or remotely to 
Table 1. Standardized ACP Checklist 

 
 
4 
complete informed consent and other study procedures. Recruitment flyers and word-of-mouth will be used to raise 
study awareness.
D5. Data collection procedures. 
D5.1 Pre-data collection procedures. During the study team 
member will inform the candidate that incentives will be 
given in person and the participant will receive a total of $75 
in physical gift cards for study participation ($25 for baseline 
outcome measure completion (Visit 1), $25 for completion of 
the 15-20 minute debrief interview (Visit 2), and $25 for the 
follow-up data completion at 30-days post-intervention (Visit 
3)). If eligible, the study team member will schedule a 
convenient time to meet with the candidate to complete 
informed consent prior to data collection, within 
approximately 14 days of initial contact. During Visit 1:  with 
the participant, electronic consent and any identifier data will 
be entered directly into REDCap [7]. A signed consent copy 
will be given to the participant. A unique study ID will be 
created for the questionnaire procedures and kept separate 
from any participant identifiers. Consent procedures will take 
10 to 30 minutes. Prior to audio-recording the qualitative interview, the PI ask permission to record.  
D5.2 Data collection procedures. During Visit 1 and Visit 3, the questionnaire will be administered to each 
participant in-person by the study team member. For in-person questionnaire administration, a copy of the questions 
and responses will be available to the participant to reference. The KSP will enter participant responses directly into 
REDCap using a tablet computer. If internet is inaccessible, responses will be recorded on paper using the 
participant’s study ID. If in-person procedures are not possible, but the participant has access to a computer and 
internet (i.e., to complete e-consent), and a telephone, interviews will be completed remotely by telephone. The Visit 
1 questionnaire procedures will take approximately 45 minutes and the Visit 3 questionnaire of fewer items will take 
approximately 30 minutes. Qualitative Debrief Interview: The PI will complete the intervention and then commence 
the 15-20-minute audio-recorded interview using a semi-structured interview guide. This interview will focus on the 
participant’s perceptions of the intervention, any moments of discomfort, stress, or discomfort, and suggestions for 
how to align the intervention with TIC principles (e.g., how can we make you feel safer during this discussion). 
Intervention Fidelity: Members of the PI’s mentor team or a peer at the Vanderbilt University School of Nursing will 
attend a random visit for approximately 20% (6) of the visits to observe the interaction, record conversational content 
using the ACP checklist, and, after the intervention and debrief visit are complete, will discuss observations with the 
PI and discuss ongoing adaptations to the checklist to align it with TIC principles.  
D5.3 Post-data collection procedures. After each time of data collection is complete, the KSP will facilitate the $25 
gift card incentive as a token of gratitude for each participant’s time. This amount is in line with other studies 
operating at the study site. The study team will audit quantitative data within 1-2 days following data collection to 
ensure completeness and accuracy. If REDCap data collection was not possible during the interview, quantitative data 
will be entered into REDCap immediately. A copy of the paper survey will be scanned into the REDCap record, to 
promote data integrity, and then shredded. We will facilitate data transparency by sharing results with participants per 
their preference. Audio-recorded data will be professionally transcribed by Rev.com and securely stored. 
D6. Limitations. This innovative single-arm, pre-post intervention study will include both qualitative and quantitative 
methods, gather preliminary data on initial efficacy and implementation outcomes, and will be a vital step for future 
work adapting our intervention and conducting larger studies assessing the effectiveness within marginalized 
communities. This study is limited by collecting data from a single arm, which does not allow for between group 
comparison, however, this approach is appropriate for introductory studies to explore within-group differences in 
efficacy outcomes and initial acceptability, feasibility, and adaptability of an ACP intervention. Face-to-face data 
collection methodology is subject to biased responses from social desirability and racial discordance, which will be 
handled by using trust-building techniques from instrument experts and community-engaged researchers (e.g., using 
community partnerships for recruitment, framing the participant as the expert informant, and asking for their help) 
[26, 27]. The mode of in-person, questionnaire delivery will assist participants with health or reading literacy 
challenges and prevent exclusion of participants with insufficient technology or transport [26]. The intervention 
delivery within the novel resiliency hub model will enable a safe, private, and supportive setting to explore planning 
needs and goals. Additionally, the strong community partnership, robust experience of the research team, and 
Figure 3. Study Activities across Three Visits 

 
 
5 
previous research success with this community enable a rigorous approach that will enable completion of all study 
activities within the 12-month funding period. 
D7. Instruments and variables. 
Validated measures will be used for Aim 1 and the quantitative portion of Aim 2 [28-30]. Background characteristics 
will include demographics, social determinants of health (PRAPARE-18) [31], Health Literacy (BHLS-3) [32], and 
anxiety/depression (PHQ-4) [33]. Intervention variables that will be used to shape the TIC adaptation include adverse 
childhood experiences (ACE-10) [34] and death-related experiences (6 items) [35]. All variables were selected per the 
relevant ACP, TIC, and Implementation Science literature 
[23, 
30, 36].  
E. Statistical Analysis Plan and Sample Size: 
 
Aim 1: Randomly missing item responses within measures 
will be handled via each measure’s specific scoring 
protocol. Although minimal missing data are anticipated 
based on preliminary descriptive research using in-person 
data collection, missing responses for entire measures will 
not be assumed random and imputations will not be 
conducted. Quantitative data analysis will be conducted 
using SAS or IBM SPSS statistics software and performed 
by Dr. Kimpel, with additional guidance from Dr. Mary 
Dietrich, as needed. Descriptive summaries of participant characteristics will be generated to inform the 
generalizability of our population estimates. Bootstrapped bias-corrected 95% confidence intervals will be generated 
around the observed sample proportions (categorical data), means (normally distributed continuous), and medians 
(skewed continuous). We have specified clinically important standards for demonstrating efficacy in Table 1. 
Frequency distributions summarizing the proportion of participants meeting the standards for demonstrating efficacy 
at 30-days follow-up will inform whether at least 80% met the standard. Furthermore, we will generate effect statistics 
with a 90% confidence interval to inform the powering of subsequent work. We will conduct tests of differences 
between pre and post-intervention ACP scores (e.g., Wilcoxon Signed-Rank Tests) as another preliminary test of the 
initial effect of the intervention on key outcomes. Aim 2: We will statistically and visually describe scores on each 
implementation measure and compare scores to the benchmarks decided on with our stakeholders as indicating 
adequate acceptability, appropriateness, and feasibility.  Sample Size Justification and Power: The primary 
outcomes of the study are initial efficacy and acceptability, appropriateness, and feasibility of the ACP intervention. 
To optimize the information gleaned about the intervention, we have by design did not include any “control” 
condition and have not used a power analysis to motivate sample size. We are justifying our sample size based on the 
number of participants that we anticipate can reasonably enroll and complete all study measures during the funded 
period. Furthermore, 30 participants will suffice for generating relative stable parameter estimates of efficacy for 
informing future work. For the qualitative analysis, thirty interviews will more than suffice to reach data saturation, 
when no new themes emerge. 
 
Table 2. Key Outcomes 
Variable (Measure) 
Time 
Period 
Aim 
Purpose 
ACP Processes: ACP Processes 
Scale (15-items, 5-point Likert scale 
(1 = almost never, 5 = almost 
always, participants rate how often 
they participate in different ACP 
processes. Higher summed scores 
indicate higher participation in ACP 
processes, e.g., I review my advance 
care documents so that I know what 
they say)) 
Baseline, 
30-day 
follow-
up 
Aim 
1 
This scale assesses the frequency 
of participation in ACP 
processes. We hypothesize that at 
30-day follow-up ≥80% of the 
participants will endorse ACP 
process scores as anticipated 
compared with <80% at baseline. 
Possible scores: 15-75 
Anticipated scores at baseline: 
<37; at 30-day follow-up: ≥37 
ACP Values/Beliefs: ACP Values 
and Beliefs scale (7-item, 5-point 
Baseline, 
30-day 
Aim 
1 
This scale assesses ACP 
misconceptions. We hypothesize 
Table 2. Study Timeline Over Two Years 

 
 
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Likert (1=strongly agree, 5=strongly 
disagree, lower scores=fewer ACP 
misconceptions) 
follow-
up 
that at 30-day follow-up at least 
80% of participants will hold 
ACP misconceptions as 
anticipated compared with <80% 
at baseline. 
Possible scores: 7-35 
Anticipated scores at baseline: 
<28: at 30-day follow-up: ≥28 
ACP Actions: ACP Stages of 
Change Scale (6-items, 5-point 
Likert (0=no, not at all, 4=yes, I’ve 
done that months or years ago, 
higher scores on individual items 
and overall=higher ACP 
participation) 
Baseline, 
30-day 
follow-
up 
Aim 
1 
This scale indicates the stage of 
change (precontemplation to 
maintenance) that each 
participant is in for the six core 
ACP actions/behaviors. We 
hypothesize that at 30-day 
follow-up ≥80% of participants 
will report ACP actions as 
anticipated compared with <80% 
at baseline. 
Possible overall scores: 0-24 
Anticipated overall scores at 
baseline: <14, at 30-day follow-
up: ≥14 
Possible scores for individual 
ACP actions: 0-4 
Anticipated individual scores at 
baseline: 0-2, at 30-day follow-
up: 3-4  
Implementation outcomes: 
Acceptability (4-item, AIM), 
Appropriateness (4-item, IAM), and 
Feasibility (4-item, FIM) 
30-day 
follow-
up 
Aim 
2 
Each of these scales indicates 
participant perceptions of 
acceptability (agreeableness, 
appropriateness (good fit), and 
feasibility (implementability) of 
the intervention. We hypothesize 
that 80% of participants will find 
the intervention to be acceptable, 
appropriate, and feasible as 
reflected in the anticipated 
scores. 
Possible Scores for each 
subscale: 5-20 
Anticipated scores at 30-day 
follow-up: 80% of the 
participants will rate the 
intervention ≥15 for each of the 
subscales 
 
 
 

 
 
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