Objective. To examine the effect of an advance care planning video intervention in nursing homes on resident outcomes of hospital transfer, burdensome treatment, and hospice enrollment.
Design. Pragmatic cluster randomized controlled trial.
Setting and participants. The study was conducted in 360 nursing homes located in 32 states across the United States. The facilities were owned by 2 for-profit nursing home chains; facilities with more than 50 beds were eligible to be included in the study. Facilities deemed by corporate leaders to have serious organizational problems or that lacked the ability to transfer electronic health records were excluded. The facilities, stratified by the primary outcome hospitalizations per 1000 person-days, were then randomized to intervention and control in a 1:2 ratio. Leaders from facilities in the intervention group received letters describing their selection to participate in the advance care planning video program, and all facilities invited agreed to participate. Participants (residents in nursing homes) were enrolled from February 1, 2016, to May 31, 2018. Each participant was followed for 12 months after enrollment. All residents living in intervention facilities were offered the opportunity to watch intervention videos. The target population of the study was residents with advanced illness, including advanced dementia or advanced cardiopulmonary disease, as defined by the Minimum Data Set (MDS) variables, who were aged 65 and older, were long-stay residents (100 days or more), and were enrolled as Medicare fee-for-service beneficiaries. Secondary analysis included residents without advanced illness meeting other criteria.
Intervention. The intervention consisted of a selection of 5 short videos (6 to 10 minutes each), which had been previously developed and tested in smaller randomized trials. These videos cover the topics of general goals of care, goals of care for advanced dementia, hospice, hospitalization, and advance care planning for healthy patients, and use narration and images of typical treatments representing intensive medical care, basic medical care, and comfort care. The video for goals of care for advanced dementia targeted proxies of residents rather than residents themselves.
The implementation strategy for the video program included using a program manager to oversee the organization of the program’s rollout (a manager for each for-profit nursing home chain) and 2 champions at each facility (typically social workers were tasked with showing videos to patients and families). Champions received training from the study investigators and the manager and were asked to choose and offer selected videos to residents or proxies within 7 days of admission or readmission, every 6 months during a resident’s stay, and when specific decisions occurred, such as transition to hospice care, and on special occasions, such as out-of-town family visits.
Video offering and use were captured through documentation by a facility champion using a report tool embedded in the facility’s electronic health record. Champions met with the facility’s program manager and study team to review reports of video use, identify residents who had not been shown a video, and problem-solve on how to reach these residents. Facilities in the control group used their usual procedures for advance care planning.
Main outcome measures. Study outcomes included hospitalization transfers per 1000 person-days alive among long-stay residents with advanced illness (primary outcome); proportion of residents with at least 1 hospital transfer; proportion of residents with at least 1 burdensome treatment; and hospice enrollment (secondary outcomes). Secondary outcomes also included hospitalization transfers for long-stay residents without advanced illness. Hospital transfers were identified using Medicare claims for admissions, emergency department visits, and observation stays. Burdensome treatments were identified from Medicare claims and MDS, including tube feeding, parenteral therapy, invasive mechanical intervention, and intensive care unit admission. Fidelity to video intervention was measured by the proportion of residents offered the videos and the proportion of residents shown the videos at least once during the study period.