Improving Palliative Care in the Home and Community: Building CAPACITI (Community Access to Palliative Care Via Interprofessional Primary Care Teams Improvement) Cluster Randomized Controlled Trial
Phase: NA
Conditions: Palliative Care
Sponsor: McMaster University

 
 
Improving palliative care in the home and community: Building CAPACITI  
(Community Access to PAlliative Care via Interprofessional primary care Teams Improvement) 
Wave 2 Cluster Randomized Controlled Trial 
 
 
 
 
Principal Investigator 
Dr. Hsien Seow, Assistant Professor, McMaster University, Department of Oncology 
 
 
 
 
Co-Investigators 
Denise Marshall (McMaster), Sammy Winemaker (McMaster), 
Frances Kilbertus (NOSM), Kathy Kortez-Miller (Lakehead),  
Kelli Stajduhar (UVictoria), Greg Pond (McMaster), 
Melissa Brouwers (Ottawa), Robin Urquhart (Dalhousie),  
 
 
 
 
 
 
 
 
Department of Oncology, McMaster University and Juravinski Cancer Centre 
699 Concession Street, Rm, 4-229 
Hamilton, ON, L8V5C2 
Contact: seowh@mcmaster.ca 
 
 
 
 
Study Protocol   
version 1 
 
 
Trial Registration: ClinicalTrials.gov NCT05120154 
 
 
July 8, 2021 
 

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1. BACKGROUND: Palliative care (PC) is an approach to care that emphasizes quality-of-life 
rather than curative treatment for patients with advanced illness and their families.1 Of the 
250,000 Canadians and 100,000 Ontarians who die annually,2 it is estimated that >80% could 
benefit from PC.3 This research focuses on the problem of improving access to PC, in 
particular home-based PC, in Canada.4,5 Home-based PC is defined in this study as receiving 
PC by a generalist primary care physician (non-specialist) in the home or community (non-
institution). Systematic reviews, summarizing results from many randomized trials, showed 
home-based PC—delivered by physicians working in interprofessional teams—improved 
quality-of-life, reduced symptom burden (e.g. pain, dyspnea, etc.), and lowered caregiver 
distress.6-11 Providing home-based PC is aligned with patient preferences as >80% of patients 
prefer to die at home,12,13 yet 65% of Canadians die in hospital.14 Despite the clear benefits of 
home-based PC, most dying Ontarians do not have access to it; and if they do, receive it very 
near death. An Ontario study of patients in their last year of life showed <10% received home-
based PC by a primary care physician, mostly occurring in the month before death.15 We focus 
on primary care physicians in this grant because evidence shows that home-based PC by a 
primary care physician reduces hospital deaths by half,16,17 yet every year 40% of primary care 
physicians do not bill for any PC service.18 Access to home-based PC is even less in rural, 
northern, and First Nations communities.19  
 
Why do so few Ontarians have access to home-based PC? As PC evolved into a specialty 
in Canada, PC specialists began to be seen as the only providers of home-based PC, thereby 
reducing primary care providers’ knowledge, confidence and role clarity in PC. But high-quality 
PC need not be exclusively delivered by specialists or in hospitals. Systematic reviews show 
home-based PC can be effectively delivered by primary care physicians working in primary care 
teams, when provided appropriate training and support.20,21 This evidence defined efficacious 
primary care teams as: teams of interprofessional providers, with primary care physicians and 
nurse coordinators at a minimum, and often times social workers, psychospiritual counselors, 
and other allied health providers.22 Research also shows many primary care providers are willing 
to provide home-based PC, but lack support to build their team’s PC “capacity”23,24—defined in 
this proposed study as having enhanced knowledge, skills, tools, and practice supports for 
effective team collaboration and local system coordination. 
There are compelling reasons to better integrate primary care and home-based PC. 
Research shows we have grossly insufficient numbers of specialist physicians to serve the 
growing need. Co-PI (HS) co-led a study that identified only 109 specialist PC physicians in 
Ontario, of which <30 worked in the home and community.18 Moreover, nearly all Canadians 
have a primary care provider. Considering longitudinal relationships and continuity of care, 
primary care providers are ideally positioned to identify the need for PC and initiate it earlier 
themselves among their patients.25 Besides better patient care, research also shows home-based 
PC reduces healthcare costs by avoiding hospitalizations.8,17,22,26 The last year of life represents 
10-25% of the total annual healthcare budget,27 of which hospitalizations comprise 70% of 
costs.28 Furthermore, the passing of the Bill C-14 in 2016, legislating Medical Assistance In 
Dying, underscores the urgent need to increase access to PC as an alternative to hastened death.29 
Thus to increase access to PC to more Ontarians, we need to develop capacity for primary care 
teams to deliver home-based PC, using a model adaptable to the local context and diverse 
communities.  
 
 
 

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2. CAPACITI PROGRAM: To address this gap, our study team proposes a quality 
improvement intervention called CAPACITI: Community Access to PAlliative Care via 
Interprofessional Teams Improvement. CAPACITI is PC training and coaching program for 
primary care teams, comprised of three, two-month (4 session) modules. Each module addresses 
a critical component of implementing a PC approach into primary care practice: (1) Identify and 
Assess; (2) Enhance Communication Skills; (3) Enhance Skills for Ongoing Care (including 
involvement of family and specialists). Over bi-monthly (one hour) sessions, each CAPACITI 
module uniquely integrates 3 components: clinical education in the form of expert advice and 
tips; evidence-based tools; and high-facilitation and expert coaching for adaptation to local 
context. CAPACITI is different from many PC interventions as it does not add new human 
resources or automatically refer to specialists; instead it builds capacity within the existing 
primary care team so they themselves can work together differently and provide more access to 
home-based PC. Thus built-capacity is more likely to be sustained beyond the program. 
International experience has demonstrated that a very similar training program, the Gold 
Standards Framework (GSF), was highly effective.30 GSF is an intervention in the United 
Kingdom (UK) that has successfully built PC capacity in primary care, hospitals, and long-term 
care for over 15 years. GSF is a PC training program complete with education, materials, and 
tools (14 hours of training taught across 6-12 months). The GSF program has been extensively 
evaluated. A critical review of 15 publications evaluating GSF found that the “greatest benefits” 
of the GSF program was it facilitated teams to identify more patients on a PC registry and 
improve their coordination practices.30 For instance, one study of 10 primary care teams showed 
that among the 1% expected annual deaths, teams provided home-based PC to 12% of patients 
before GSF which rose to 52% after GSF (range 31% to 107%).31 Other GSF literature has 
corroborated this finding: after GSF, primary care teams were able to identify 65% (range 35% 
to 90%) of the 1% of expected deaths as requiring home-based PC.32 The critical review also 
found consistent evidence that post-GSF, teams provide PC earlier before death, reduce hospital 
deaths by 50%; have more interprofessional teamwork and communication; and increase family 
caregiver satisfaction.30 GSF has been implemented in literally thousands of primary care teams 
across the UK. However, GSF’s success was in part due to 3 contextual factors that exist in the 
UK but not in Canada: an organized network of primary care trusts, end-of-life and PC patient 
registries via widespread electronic medical records, and financial incentives for reaching targets 
in the PC registry. 
CAPACITI is an enhanced version of GSF, where our team maintained GSF’s strengths 
but modified it for the Canadian context. In addition, what makes CAPACITI particularly novel 
is that our team emphasizes practice supports in each module on clinical education or tools and 
utilizes high-facilitation and expert coaching. Together these unique modifications to GSF help 
primary care teams better operationalize PC delivery in Canada. Context-relevant practice 
supports are critical because knowledge translation (KT) evidence has shown that education or 
tools alone do not change practice without context-relevant KT on system integration.33-35 For 
instance, education programs teach clinicians drug dosages for optimal management of complex 
symptoms, but offer little guidance on ensuring timely delivery of drugs to patients at home day 
or night. High-facilitation and expert coaching are critical to manage change initiatives and 
overcome KT challenges unique to the local context.  
The recently completed pilot study of CAPACITI (Wave 1) with 27 teams across 
Ontario, demonstrated the feasibility and efficacy of this intervention. This version of 
CAPACITI featured 10 shorter modules, provided in monthly sessions over one year. Similarly, 
this iteration offered monthly webinars, accompanied by assigned activities and active 

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facilitation. The intervention was evaluated using pre and post survey data reported by team 
members, session feedback, and focus groups with the teams. The program showed potential for 
helping primary care teams operationalize an early PC approach. The CAPACITI content and 
program structure were revised based on the findings of the pilot study. The 10 sessions in the 
pilot intervention were bundled into 3 independent modules, which will be each held over a 
period of 2 months, so that teams can select the module(s) relevant to them and complete this 
material in a shorter time. We conducted further literature reviews to integrate a comprehensive 
inventory of effective and relevant PC education programs, training materials, clinical and 
collaboration tools, and measurement surveys relevant to primary care. Based on the pilot work, 
both the CAPACITI intervention and the study measures have been refined and their potential 
effectiveness increased. In the current study, CAPACITI will be provided to teams using a 
learning management system and evaluated as a cluster randomized controlled trial. 
In this project, we propose the optimal model for implementing the CAPACITI modules, 
with trained staff facilitators, local specialist mentors and expert coaches. We will evaluate this 
intervention in a cluster randomized controlled trial. We engaged KUs representing the provinces 
(e.g., OPCN) and primary care provider teams themselves to ensure participation, feasibility, and 
adequate sample size. We also engaged national, multi-provincial, and patient collaborators. The 
knowledge generated from this study will be high-quality, generalizable, and ready for spread 
across diverse regions in Canada. 
 
3. GOALS AND OBJECTIVES: The main goal of the Second Wave of this study is to provide 
a revised version of CAPACITI to a new set of primary care teams in Ontario and to use a 
randomized controlled trial methodology to compare the effect of this program, delivered 
facilitated versus unfacilitated, on teams’ abilities to increase patient access to, and team capacity 
for, home-based early palliative care. CAPACITI Wave 2 feature three distinct education 
modules, each which will be evaluated individually. 
 
PRIMARY OBJECTIVES: To determine if teams differ in the below both between trial arms 
(facilitated versus unfacilitated) and within teams before versus after CAPACITI:  
1. PC access and timing, measured as a) Percent of patients in the past 3 months identified as 
requiring a palliative care approach, and b) Typical timing of when to initiate a palliative care 
approach for cancer and non-cancer patients respectively. 
2. PC competency, measured as team member competency in providing key tenets of palliative 
care using the validated EPCS. 
3. Assignment completion and perceived change in practice, reported upon completion of 
the module using the Assignment completion and change survey. 
 
SECONDARY OBJECTIVES: To determine if teams between study arms and pre/post 
CAPACITI differ in:  
1. CAPACITI confidence in PC, where primary care team member’s capacity is measured by 
confidence in palliative care skills specific to the CAPACITI modules using our own 
CAPACITI competencies survey. 
2. Team interprofessional collaboration, measured by team member’s perceptions how they 
work and act together in terms of partnership, cooperation, and coordination using the 
AITCS-II. 
3. Team satisfaction with CAPACITI, measured by team member’s assessments of module 
sessions (post module only). 

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4. CAPACITI effectiveness by context, measured by team’s perceptions of program overall 
and using qualitative interviews or surveys (post module only). 
5. Program analytics, measured through the Learning Management System, including module 
pages accessed by team members, time spend on platform, quizzes completed, etc. 
6. Effectiveness on above outcomes by co-variates, factors impacting effectiveness of 
program (of other outcomes) according to team and individual member characteristics (e.g. 
profession, rurality, ORCA readiness, etc.). 
 
4.0. METHODS 
 
4.1. STUDY DESIGN: Our study design is a prospective cluster randomized controlled trial of 
interprofessional primary care teams who register for CAPACITI Wave 2 modules. CAPACITI 
offers three distinct educational modules, each which will be evaluated separately. The primary 
comparison will be between the trial arms upon completion of a module. Our study will also 
measure the change in outcomes within the same team, before and after completion of a module.  
 
4.2. STUDY ARMS: Both the intervention and control groups will have access to all the 
CAPACITI module materials, provided on a learning management system. The intervention 
group will receive module facilitation, that is, coverage of module materials in four live webinars 
(bimonthly for the 2 month duration of the module = 4 webinars). The control group will not 
receive module facilitation (i.e., will entail self-directed learning). 
 
4.3. RANDOMIZATION: Teams who register for a module will be randomized to either the 
intervention or control arm using a permuted block design to ensure groups of equal sizes.36 The 
sequence of allocation will computer-generated and each assignment placed in a numbered 
sealed envelope, which will de consecutively opened for each team that registers for a module. 
For teams that register for multiple modules, randomization to either the intervention or control 
arm will occur independently for each module. That is, group allocation for a module does not 
predetermine that for future, different modules. Teams that wish to retake a module can select 
the group to which they are allocated – no further data will be collected from the team for that 
module. Teams will be stratified by province and team size. 
 
4.4. STUDY POPULATION: Our study is expected to include 60 interprofessional primary 
care teams per module (10 teams per term, each offered for 6 terms [times]), who meet the below 
inclusion criteria and are willing to participate in at least one CAPACITI module. Each team will 
have between 3 and 10 members participating in the module for an expected total of 300 team 
members (60 teams x 5 members/team). The teams will come from across Canada and will be 
geographically diverse (e.g. rural, urban, and remote), which is critical to generating evidence on 
generalizability in diverse communities across the country.  
 
4.5. INCLUSION CRITERIA: Each team must: 
• Be an interprofessional “team”, defined as having a minimum of a: family physician or nurse 
practitioner; and practice coordinator. They can have other team members (e.g. social 
worker, pharmacist, etc.). 
• Be community-based and willing to provide PC in patient’s homes, defined as managing 
symptoms, addressing psychosocial needs, educating patients and families, and coordinating 
care. 

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• Have a minimum of three team members who agreed to participate in a CAPACITI module 
and complete the course measures. 
 
4.6. RECRUITMENT: 
Study participants will be members of primary care teams that enroll in CAPACITI. Potential 
teams across Canada will be informed about CAPACITI through advertising by our partner 
stakeholders and organizations, including Pallium Canada, Hospice Palliative Care Ontario, 
Saint Elizabeth Health Care, Canadian Hospice Palliative Care Association, and provincial 
professional associations, e.g., Medical Association of Ontario. The 18 co-Is will also 
disseminate to their provincial partners, e.g., BC Centre for Palliative Care to promote the 
program (see CAPACITI Program Information sheet). CAPACITI will be offered across 6 terms, 
with rolling enrollment for the modules which are all repeated each term. The program will be 
offered free to teams, with the understanding that those participating will complete the 
educational and data collection components. 
 
4.7. EVALUATIVE FRAMEWORK: We will use the Kirkpatrick Model, a globally 
recognized training evaluation framework, to frame the various program evaluation components. 
This model outlines 4 critical domains of an effective training program1:  
• Reaction: The participant’s reaction or satisfaction to the education program.  
• Learning: The participant’s acquired knowledge and skills from the education program.   
• Behaviour: The participant’s application of what they learned during the program to their 
practice. 
• Results: The direct outcomes, e.g., patient outcomes, that occur as a result of the 
education program.  
The Summary of Data Outcomes Table below summarizes how we will access each of the 
domains in the Kirkpatrick Model 
 
4.8. OUTCOMES: We will use quantitative (validated survey tools) and qualitative (semi-
structured focus groups) methods. Quantitative outcomes will be measured per module as the 
difference between the intervention and control arms, immediately following completion of the 
module. We will also measure change in the outcomes for each team member before versus after 
a module. 
 
PRIMARY OUTCOMES:  
1. PC access and timing, measured based on self-reported i) number of patients in caseload 
and number (calculated %) reported as Identified as requiring a palliative care approach, ii) 
Typical timing of when to initiate a palliative care approach for cancer and non-cancer 
patients respectively. 
2. PC competency, measured by scores on the End-of-life Professional Caregiver Survey 
(EPCS) 
3. Assignment completion and perceived change in practice, measured by number of module 
assignments attempted/completed (checklist) and reported change in thinking, behaviour, 
processes and patient/family experience (Assignment Completion & Change Survey) 
 
 
 

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SECONDARY OUTCOMES: To determine if teams between study arms and pre/post 
CAPACITI differ in:  
1. CAPACITI confidence in PC, where primary care team member’s capacity is measured by 
scores on the CAPACITI Competency Survey. 
2. Team interprofessional collaboration, measured by scores on the Assessment of 
Interprofessional Team Collaboration Scale II (AITCS II). 
3. Satisfaction with CAPACITI program measured by team members’ Session evaluations 
(poll survey). 
4. CAPACITI effectiveness by context, measured by team’s Perceptions of program overall 
(team focus group). 
5. Program analytics, for each team member measured through the Learning Management 
System (module pages accessed, time spend on platform, quizzes completed, session 
attendance). 
6. Effectiveness on above outcomes by co-variates, contextual factors impacting effectiveness 
of program outcomes, specifically across self-reported: i) Team/member characteristics, ii) 
Individual’s level of readiness, measured by scores on the Organizational Readiness to 
Change Assessment survey (ORCA), and iii) Individual’s preferred learning style. 
 
Summary of Data Outcomes and Measures by Framework Domain 
Data Outcome 
Kirkpatrick Model 
Domain Assessed 
Outcome Measure/Instrument 
 
Primary 
 
 
1. PC access and timing 
Results 
Access: Total case load, # identified PC,  
Timing: Typical timing of when first palliative care will 
be initiated for cancer and noncancer patients  
2. PC competency 
Learning 
End-of-life Professional Caregiver Survey (EPCS) – 20 
items 
3. Assignment 
completion / Change in 
practice 
Learning 
Behavior 
Results 
Checklist of completion of module specific assignments 
(study created survey) 
Change survey – 4 items 
Secondary 
 
 
1. CAPACITI 
confidence 
Behavior 
CAPACITI Competencies Survey – 20 items 
2. Team 
interprofessional 
collaboration 
Behavior 
Assessment of Interprofessional Team Collaboration 
Scale II (AITCS II) – 23 items 
3. Satisfaction with 
program 
Reaction 
 
Perception of webinar content Self-report poll – 4 items 
4. CAPACITI 
effectiveness by context 
Reaction 
Learning 
Behavior 
Semi-structured focus groups to access team perceptions 
of the CAPACITI-FNIM program 
5. Program analytics 
Reaction 
LMS metric tracking (# participants, module completion, 
time spent in session, downloads) 
6. Effectiveness on 
above outcomes by co-
variates 
Impact on all domains 
Team Registration Form (location, electronic medical 
record platform, etc.) 
Team Member Registration Member Form (profession, 
learning preference, PC training, years in role, etc.) 
Organizational Readiness to Change Assessment survey 
(ORCA) – 31 items 
 
 

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4.9. DATA SOURCES AND DATA COLLECTION: 
All data will be collected online, self-reported through the Learning Management System. 
 
Team Registration Form  
Team characteristics and module registration. Includes team name, location, electronic medical 
record platform, team members. 
 
Team Member Registration Form  
Team member demographics. Includes profession, role, PC training, years working with team, 
remuneration model, preferred learning style (self-directed or group facilitated), team PC 
practice (total patients seen in last 3 months, # identified PC in last 3 months, timing of when to 
initiate PC for cancer patients, timing of when to initiate PC for non-cancer patients) 
 
Organizational Readiness to Change Assessment survey (ORCA). We will use a modified version 
of the ORCA to ensure that the items are relevant to the CAPACITI modules.37 The ORCA 
measures organizational readiness to implement evidence-based practices in clinical settings. 
The survey was developed from the Promoting Action on Research Implementation in Health 
Services (PARIHS) framework, a theoretical model to guide implementation of evidence-based 
interventions. The original version of the ORCA consists of 77 items, with subscales, grouped 
according to the main areas of the PARIHS framework, and organized by 3 major domains: 
Evidence, the nature and strength of the evidence and its potential for implementation (4 
subscales); Context,  the environment or setting in which the proposed change is to be 
implemented (6 subscales); Facilitation, capacity or types of support needed to help people 
change their attitudes, behaviours, skills and ways of thinking and working (9 subscales). Each 
item is scored on a 5-point Likert scale rating the strength of agreement with each statement, 
from 1 (strongly disagree) to 5 (strongly agree). Reliability tests indicate that most subscales of 
the ORCA tool meet standard requirements of internal consistency of alpha >0.80. The ORCA is 
intended to be modified to ensure applicability to the intervention being assessed – the modified 
version for out study contains a total of 31 items with 8 subscales.  
 
Module Surveys  
Module surveys will be completed by participants from all teams before (T1) and after the 
module (T2) and at 12 months following module completion (T3). 
 
End-of-life Professional Caregiver Survey (EPCS). The EPCS is a 28-item scale developed to 
assess palliative care-specific educational needs within an interprofessional team related to three 
main subdomains: Effective Care Delivery (ECD 8-items); Patient and Family-Centered 
Communication (PFCC 12-items); and Cultural and Ethical Values (CEV 8-items) (Lazenby, 
2012). Each item is scored on a 5-point Likert scale ranging from 1 (lowest level of skill) to 5 
(greatest level of skill). Items represent care-provider comfort with a variety of situations related 
to palliative and EOL care. The EPCS covers all eight domains of the national palliative care 
guidelines and core lessons of physician-specific and nurse-specific end of life education 
curricula in the USA. The EPCS exhibits strong internal consistency (alpha = 0.96). For the 
purposes of this study we will exclude the CEV sub-domain items from the EPCS. 
 
CAPACITI Competencies Survey. The CAPACITI Competencies Survey is a study created 
questionnaire based on the CanMEDS framework for improving patient care by enhancing 

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physician training and the topics covered in the CAPACITI program. CanMEDS, developed by 
the Royal College of Physicians, delineates critical competencies to effectively meeting the 
health care needs of patients, including communication, expertise, collaboration, advocacy, and 
commitment (cite https://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e). Each item 
is scored on a 7-point Likert scale ranging from 1 (lowest level of confidence) to 7 (greatest level 
of confidence). The Competencies Survey was developed and tested in Wave 1 of CAPACITI. 
The CAPACITI Competencies Survey exhibits strong internal consistency (alpha = 0.96). 
 
Assessment of Interprofessional Team Collaboration Scale II (AITCS II). The AITCS is an 
instrument designed to measure interprofessional collaboration among team members. The 
AITCS consists of 23 items considered characteristic of interprofessional collaboration (how 
team works and acts). Scale items represent three elements considered to be key to collaborative 
practice. These subscales are: Partnership (8 items), Cooperation (8 items), and Coordination (7 
items). Each item is scored on a 5-point Likert scale indicating the extent to which the team 
exhibits each, ranging from 1 (Never) to 5 (Always). Internal consistency estimates for reliability 
of each subscale range from 0.80 to 0.97, with an overall reliability of 0.98 
 
Assignment Completion & Change Survey. This survey is a two-part, study created questionnaire 
based on the CAPACITI module activities. Part A is unique to each module, asking participants 
to indicate the extent to which they were able to complete each of the session assignments for the 
module. Response options are: Have not started (1), Started but not completed (2), Completed 
(3). Part B contains four items assessing changes in thinking, behaviour, processes, and 
patient/family experience, respectively. Each item is scored on a 5-point Likert scale, rating the 
strength of agreement with each element of change, from 1 (strongly disagree) to 5 (strongly 
agree). 
 
Module Session Evaluation  
Participants will be asked to complete an evaluation poll at the end of each module session, 
consisting of 4 items: 3 items scored on a 5-point Likert scale ranging from 1 (Not at all/ Poor/ 
Not successful) to 5 (Very likely/ Excellent / Extremely successful) and 1 dichotomous item 
assessing perceived bias (Yes/No). 
1. How likely are you to adopt at least one idea or concept from this session in your practice 
or organization? 
2. How would you rate this webinar overall? 
3. How successful were we in meeting the objectives in providing tools, knowledge or tips?  
4. Do you perceive any degree of bias in any part of this webinar? 
 
Post Module Team Focus Groups 
We will conduct virtual focus group with a purposive sample of teams who complete the 
CAPACITI modules both in the intervention and control groups: 6 to 10 teams in each arm PER 
MODULE (12 to 20 teams total, 60 to 100 team members total). The focus group discussion 
guide was developed and tested in Wave 1 of CAPACITI. In the focus group we will inquire if 
implementation was perceived as successful (If so, how? If not, why?) and what were the 
barriers and facilitators. The interview data will be supplemented by field notes maintained by 
staff during the study. (See appendix for focus group discussion guide) 
 

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Data Collection Schedule 
Team 
Registration 
Team Member 
Registration 
Pre Module  
Post Module 
12 Months Post 
Module 
Team 
Characteristics 
(e.g., region) 
Individual 
Demographics and 
Characteristics (e.g., 
profession) 
End-of-Life 
Professional Caregiver 
Survey (EPCS) 
End-of-Life 
Professional Caregiver 
Survey (EPCS) 
End-of-Life 
Professional Caregiver 
Survey (EPCS) 
 
ORCA 
(Organizational 
Readiness to Change 
Assessment) Survey 
CAPACITI 
Competencies Survey 
CAPACITI 
Competencies Survey 
CAPACITI 
Competencies Survey 
 
Practice 
Characteristics  
[Total case load, # 
identified PC,  
Typical timing for first 
initiation of PC cancer 
and non-cancer] 
 
Practice 
Characteristics  
[Total case load, # 
identified PC,  
Typical timing for first 
initiation of PC cancer 
and non-cancer] 
Practice 
Characteristics  
[Total case load, # 
identified PC,  
Typical timing for first 
initiation of PC cancer 
and non-cancer] 
 
 
 
Module Session 
Evaluation (at each 
Session) 
 
 
 
 
Assignment 
Completion & Change 
Survey 
 
 
 
AITC-II survey – 
interprofessional team 
collaboration scale 
AITC-II survey – 
interprofessional team 
collaboration scale 
 
 
 
4.10. STATISTICAL POWER/SAMPLE SIZE: Sample size calculation is based on the 
assessment of the primary outcomes of Effective Care Delivery (ECD 8-items) subdomain on the 
End-of-life Professional Caregiver Survey (EPCS) and the % of patients identified as requiring a 
palliative care approach. 
Previous work using the EPCS with nurses, physicians, and social workers identified a 
mean score of 3.6 for the ECD subdomain and a standard deviation (SD) of 1.0 (scale from 1 to 
5). We assumed that a difference of 0.5 in SD (i.e., a delta of 0.5 or a half point on the scale) 
between treatment groups at T2 would be important to detect. Accounting for the cluster design, 
we estimate that the correlation between providers within teams was 0.15 and that each team 
would have a minimum of 4 members participate. Given a two-sided alpha of 0.05, a power of 
80%, 192 providers from 48 teams would be required. This will also allow for detection of a 1-
point difference increase of the % of patients identified as requiring a palliative care approach 
(SD=2). We anticipate 60 teams with an average of 5 members per team. 
 
4.11. ANALYSIS PLAN: The intervention is at both the team and individual level. The unit of 
analysis is at the individual and team level, depending on the outcome considered. 
 
Quantitative analysis (registration and survey data): Treatment groups will be compared with 
respect to registration variables (potential covariates) by tabulation methods (means, standard 
deviations, frequencies). Both team level variables (e.g., region) and member level variables 
(e.g., PC training) will be tabulated.  The primary analysis will be a between treatment 
comparison of intervention and control groups of post module scores on the primary outcomes 

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(EPCS and % identified for PC). Secondary analyses will include comparisons of all team 
outcomes. Mixed model ANOVA methods will be used, taking into account the increased 
variance due to cluster randomization, for the assessment of the primary outcomes [Donner, 
1981]. Confidence intervals (CI) for the difference of means will be calculated and adjusted for 
data clustering. Multilevel mixed models with two levels, cluster and repeated measures will be 
used to investigate the effect of the intervention over time (baseline, post module, 6 months post 
module). 
 
Qualitative Analysis (focus group data): We will conduct a thematic analysis using a constant 
comparison method along a 4-stage process based on Pope’s Framework Approach,38 as we have 
done previously:39,40 1) Focus groups will be audio taped and transcribed into a document, along 
with staff notes, for analysis. 2) The Focus group questions will be used to create a template for 
organizing each team’s data and emerging ideas. 3) Emerging ideas from each template construct 
will be coded and compared within and across teams, first independently by two analysts and 
then conjointly. Emerging themes will be compared and discussed until consensus is obtained 
between the analysts. 4) Common themes for each construct will be identified. We will maintain 
an audit trail that documents and justifies decisions in the analysis to promote consistency.41 
 
4.12. DATA ACCESS, PRIVACY, AND ETHICS: The confidentiality of all participants’ 
identities will be strictly maintained. Only research team members will have access to the data. 
Informed consent will be obtained from all provider participants. All identifying information will 
be removed from both quantitative and qualitative data once collected, to ensure no breeches in 
confidentiality. Safeguards will be undertaken to ensure the confidentiality of virtual focus group 
responses. No individual responses will be identifiable in any results shared with those outside 
the research team. No personal information such as name and email address, used to arrange the 
focus groups, will be linked to responses. Personal information will be deleted once the focus 
groups are complete. The focus groups will be digitally audiotaped, with the permission of 
participants. This is to ensure accuracy in capturing the groups’ responses. Audio recordings of 
the focus groups will only be heard by the study analyst(s) of the research team and the 
recordings will be destroyed once the study is finished (approximately after one year). These 
recordings will be transcribed, however, as mentioned, the transcript will not contain any 
identifiable information. The participant contact list and focus group responses will be securely 
stored as a password protected files on a private drive on the Juravinski Cancer Centre network. 
Ethical approval will be sought from the Hamilton Health Sciences, McMaster University 
Research Ethics Board prior to commencement of the study.  
 
5. KNOWLEDGE TRANSLATION (KT): The CAPACITI intervention represents real-time 
integrated KT with local teams of primary care providers.42 Specifically the intervention’s 
emphasis on practice supports helps teams adapt knowledge to diverse local contexts. 
CAPACITI’s high-facilitation and coaching allow for tailoring of evidence to address local 
barriers, which increases the likelihood of adopting and sustaining the intervention. We have 4 
co-Is from other provinces and collaborations with the national organization to support KT 
spread. They will help us work with regional and provincial KUs to align our research program 
with their policy directives. Our key end-of-grant deliverables are: 
• Deliver a series of KT meetings, presentations, reports, and policy briefs to share our results 
with KUs and policymakers across Canada. 
• Publish our results in peer-reviewed journals and present at relevant academic conferences. 

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• Create a national implementation report on delivering PC by primary care teams, including 
details on lessons learned, implementation strategies, and considerations for further 
implementation of the intervention across Canada and geographic diversity. 
 
6. TIMELINE: Study activities for this cRCT requires 3 years: Start-up (6 months), Intervention 
and data collection (18 months), final data analysis (6 months) and KT (6 months).  
 
7. SIGNIFICANCE: This study will generate robust evidence on the CAPACITI intervention’s 
effect on access to home-based palliative care and primary care team capacity on a large scale 
using a rigorous research methodology. In a program comprised of three distinct modules, 
CAPACITI offers clinical education and evidence-based tools, while integrating practice 
supports to improve team collaboration and system coordination, and providing high-facilitation 
and expert coaching to adapt to the local context. CAPACITI is unique because it builds capacity 
within the existing team, and does not add new front-line human resources; thus any built-
capacity is more likely to be sustained beyond the grant. Ultimately, this study will generate 
evidence that will strengthen the primary care system, increase access to home-based PC, and 
improve satisfaction for dying patients and their families in diverse communities across Canada. 
 
 

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