Advance Care Planning (ACP) in Primary Care for Dementia
Condition: Dementia; Advance Care Planning
MeSH terms: Dementia
Study type: Interventional

Summary: 
      ADVANCE-PC: Aligning Dementia & adVANce Care planning Education in Primary Care, is a
      communications and implementation support intervention that builds on existing ACP programs,
      understanding of dementia, and clinical expertise to provide training and technical
      assistance tailored to the needs of primary care clinicians and clinics that are often
      over-burdened and under-resourced. For this pilot, we will recruit six primary care clinics
      to test the ADVANCE-PC delivered using remote technology (ECHO). The pilot will include
      conducting one ECHO cycle and assessing the feasibility and acceptability of the program
      content and this mode of delivery (Aim 1) and testing pragmatic outcome assessment for the
      intervention (Aim 2).
    

Detailed description: 
      Aim 1: To assess the feasibility, acceptability, and content utility of the ECHO program
      among the clinicians in the participating primary care clinics. Data will be collected to
      assess successful program implementation and participant engagement. We will document
      outreach efforts, reporting why clinics decline to participate and as well as the initial
      motivations of those who agree. Data will be collected from participating clinicians: a
      pre-training questionnaire about their prior experience with ACP and dementia; feedback at
      the end of each session; and a longer questionnaire at the end of the training that measures
      intentions to engage in ACP, their understanding of dementia, their confidence in engaging
      patients and families in ACP, and what barriers they expect to encounter. Attendance will be
      documented, and ECHO sessions will be recorded so participation and trainee engagement can be
      assessed. At the end of the follow-up period, clinicians will participate in interviews
      focused on barriers to and facilitators of ACP in the context of dementia. Feasibility and
      acceptability of this intervention will be evaluated using descriptive and qualitative
      analyses of these data.

      Aim 2: To pilot test the ascertainment of outcomes for the ADVANCE-PC program in the 3-month
      period when trained clinicians are attempting to conduct ACP routinely in their clinics. The
      primary outcome will be the proportion of patients with dementia and/or their care partners
      seen by participating clinicians who are engaged in ACP. To pilot test pragmatic assessment
      of this outcome, we will work with clinics to determine how the number of patients with
      dementia seen in a defined period (the denominator) and number who are engaged in ACP (the
      numerator) can be efficiently identified in by each clinic using their electronic health
      record (EHR). We will collect information on EHR functionality and current dementia and ACP
      documentation during Months 1-3 and integrate support for documentation and measurement into
      the training. Our secondary outcomes are clinician confidence, intentions, and behavior
      related to ACP. These will be evaluated during the ECHO program using questionnaires modeled
      after data collection activities routinely used by clinics for quality improvement and
      formally measured and analyzed using research questionnaires pre and post completion of the
      ECHO program and a semi structured interview at the end of the follow-up period.
    

Intervention name(s): ADVANCE-PC training via ECHO
Intervention type(s): Other
Intervention description(s): To assess the feasibility of using a technology-based platform to deliver the ADVANCE-PC program to multiple primary care clinics. This model will be based on the ECHO program, a tele-mentoring program which uses communications technology to provide facilitated education, case review, and peer-to-peer problem solving remotely. Our working hypothesis is that the use of ECHO will be efficient (allowing several clinicians and teams to be supported simultaneously while creating a community of practice), feasible (that clinicians will enroll and share experiences via mentoring, guidance, feedback, and didactic education), and have the potential to impact patients as clinicians perceptions shift to favor ACP, their skills increase, and they are able to integrate ACP for patients with dementia into their clinic.
Intervention model: Single Group Assignment
Intervention model description: This is a prospective pilot study designed to achieve the objectives listed above. This project focuses on implementing ACP (which is an accepted best practice) and using ECHO (which is an evidence-based existing professional development model in healthcare). The research component involves data collection from clinicians and clinics in addition to what would be normally collected for as part of the training program and for quality improvement (QI).
Masking: None (Open Label)
Primary purpose: Supportive Care
Keywords: dementia; advance care planning; primary care; ECHO