Over the past three decades, nursing homes have evolved into complex healthcare systems serving nearly 4 million individuals annually. Given the increasing clinical complexity and advanced disease of the population, nursing homes are often charged with guiding patients through challenging decisions about the direction of their treatment. Advanced care planning is the process of communication between providers and patients/families to identify anticipated medical decisions and clarify treatment preferences. Unfortunately, advanced care planning in this setting remains suboptimal; counseling is inconsistent, care preferences are not routinely ascertained, and advance directives may not be discussed or reflect patients’ goals of care. Traditional advance care planning relies on verbal descriptions of hypothetical health states and treatments, which may be of limited utility considering complex scenarios are hard to envision, information is inconsistent, and verbal explanations are hindered by literacy and language barriers. Advanced care planning video decision support tools represent an approach that may address these shortcomings, although the effectiveness of this approach has been limited to small randomized controlled trials.
[Photo: Dr. Vincent Mor]
The purpose of this paper, led by Dr. Vincent Mor, Professor of Health Services, Policy & Practice and faculty member in the Center for Gerentology and Healthcare Research, was to describe the design and rationale of PRagmatic trial Of Video Education in Nursing Homes (PROVEN), a pragmatic cluster randomized controlled trial to evaluate an advance care planning video program. The study was conducted in 360 nursing homes owned by two healthcare systems. Over an 18-month implementation period, intervention facilities were instructed to offer the Advance Care Planning Video Program to all patients. Control facilities employed usual advance care planning practices. The intervention consisted of five videos that addressed common advance care planning decisions in nursing homes: (a) General Goals of Care, (b) Goals of Care for Advanced Dementia, (c) Hospice, (d) Hospitalization, and (e) Advanced Care Planning for Healthy Patients. The videos were in English and Spanish, 6-10 minutes in duration, and offered to patients, family members, or both. The primary outcome was the number of hospitalizations/person-day alive among long-stay patients with advanced dementia or cardiopulmonary disease.
The large number of well-characterized candidate facilities enabled several unique design features including stratification on historical hospitalization rates, randomization prior to recruitment, and 2:1 control to intervention facilities ratio. This study has the potential to promote goal-directed care among millions of older Americans in nursing homes and establish a methodology for future pragmatic randomized controlled trials in this complex healthcare setting.
This study was published in Clinical Trials, 2017 (ahead of print).
For more information: https://www.ncbi.nlm.nih.gov/pubmed/28068789