Acceptability of a nurse-led, person-centred, anticipatory care planning intervention for older people at risk of functional decline: A qualitative study

"Making an effort for the very elderly": The acceptability of a multidisciplinary intervention to retirement village residents

The retirement village (RV) population is a growing one, with many residents having unmet healthcare needs. Despite this, there is a relative paucity of research in the RV community. We previously performed a randomised controlled trial (RCT) of a multidisciplinary (MD) nurse-led community intervention versus usual care within 33 RVs in Auckland, New Zealand. Participant acceptability is an important aspect in assessing intervention feasibility and effectiveness. The aim of this current qualitative study was to assess the acceptability of the intervention in participating residents. Data were collected using semi-structured interviews designed around the Theoretical Framework of Acceptability. Thematic analysis was undertaken using a general inductive approach. Of the 199 participants in the intervention arm of the original RCT, 27 were invited to take part in this qualitative study. Fifteen participants were recruited with a median age of 89 years, 10 were female and all were of European ethnicity. Participants were generally positive about the intervention and research processes. Three themes were identified: (1) participants' understanding of intervention aims and effectiveness; (2) the importance of older adult involvement and (3) level of comfort in the research process. Despite the MD intervention being deemed acceptable across several domains, results provided learning points for the future design of MD interventions in RV residents and older adults more generally. We recommend that future intervention studies incorporate co-design methodologies which may improve the likelihood of intervention success.

Anticipatory care planning for community-dwelling older adults at risk of functional decline: a feasibility cluster randomized controlled trial

Objectives

To determine the feasibility, implementation and outcomes of an Anticipatory Care Planning (ACP) intervention in primary care to assist older adults at risk of functional decline by developing a personalized support plan.

Design

Feasibility cluster randomized control trial.

Setting and participants

Eight primary care practices (four in Northern Ireland, United Kingdom and four in the Republic of Ireland) were randomly assigned to either intervention or control arm. Eligible patients were those identified in each practice as 70 years of age or older and assessed as at risk of functional decline. Study participants (intervention n = 34, control n = 31) and research staff were not blinded to group assignment.

Anticipatory care intervention

The intervention delivered by a registered nurse including: a) a home-based patient assessment; b) care planning on the basis of a holistic patient assessment, and c) documentation of a support plan.

Outcome measures

A conceptual framework (RE-AIM) guided the assessment on the potential impact of the ACP intervention on patient quality of life, mental health, healthcare utilisation, costs, perception of person-centred care, and reduction of potentially inappropriate prescribing. Data were collected at baseline and at 10 weeks and six months following delivery of the intervention.

Results

All pre-specified feasibility indicators were met. Patients were unanimous in the acceptance of the ACP intervention. Health care providers viewed the ACP intervention as feasible to implement in routine clinical practice with attending community supports. While there were no significant differences on the primary outcomes (EQ-5D-5L: -0.07 (-0.17, 0.04) p = .180; CES-D: 1.2 (-2.5, 4.8) p = .468) and most secondary measures, ancillary analysis on social support showed responsiveness to the intervention. Incremental cost analysis revealed a mean reduction in costs of €320 per patient (95% CI -31 to 25; p = 0.82) for intervention relative to the control.

Conclusions

We successfully tested the ACP intervention in primary care settings and have shown that it is feasible to implement. The ACP intervention deserves further testing in a definitive trial to determine whether its implementation would lead to better outcomes or reduced costs.

Trial registration

Clinicaltrials.gov, ID: NCT03902743. Registered on 4 April 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03128-x.

Lessons from a feasibility study testing an anticipatory care planning intervention for older adults at risk of functional decline: feedback from implementing stakeholders

Background

Anticipatory care is becoming increasingly important in effectively managing complex multimorbidity in aging populations, preventing further functional decline, and avoiding hospital admissions. This study aimed to elicit the feedback of participating general practitioners, practice managers, nurses and an adjunct pharmacist on the implementation strengths and limitations of a nurse-led, person-centered anticipatory care planning (ACP) intervention for older people at risk of functional decline in a primary care setting. The findings have implications for a full trial and intervention design.

Methods

As part of a feasibility cluster randomized controlled trial (cRCT) testing the ACP intervention, we sought feedback from implementing stakeholders: general practitioners (N = 3), practice staff (N = 3), research nurses (N = 5), and adjunct pharmacist (N = 1) in both the Republic of Ireland (ROI) and Northern Ireland (NI), UK. Following written, informed consent, they were interviewed to investigate their experience of participating in the implementation of the ACP intervention as part of the feasibility trial, and elicit any recommendations for a full trial. Using the Consolidated Framework for Implementation Research, thematic analysis was employed to analyze data. The intervention consisted of home visits by specially trained nurses who assessed participants’ health, discussed with them their health goals and plans, and devised an anticipatory care plan following consultation with participants’ General Practitioners and the adjunct clinical pharmacist.

Results

Participating stakeholders indicated that the strengths of the implementation process included the training provided to the nurses, constructive collaboration of the research team, and structure of implementation process. Perceived limitations included the selection process and screening tool, communication between the research team and the nurses, the assessment questionnaire, and the final document left with the patient, as well as lack of access to medical records for the adjunct pharmacist. Recommendations include better communication and team-wide consensus on alterations to procedure and documents, and standardized protocols for patient selection, data collection, and reporting for research nurses.

Conclusions

The findings have identified strengths of the implementation process on which to build, and recognized limitations which can now be addressed to ensure improved efficiency and effectiveness in future trials.

Trial registration

Clinicaltrials.gov, ID: NCT03902743. Registered on 4 April 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-00973-w.

Successful implementation of a trans-jurisdictional, primary care, anticipatory care planning intervention for older adults at risk of functional decline: interviews with key health professionals

Background

Aging populations present a challenge to health systems internationally, due to the increasing complexity of care for older adults living with functional decline. This study aimed to elicit expert views of key health professionals on effective and sustainable implementation of a nurse-led, person-centred anticipatory care planning (ACP) intervention for older adults at risk of functional decline in a primary care setting.

Methods

We examined the feasibility of an ACP intervention in a trans-jurisdictional feasibility cluster randomized controlled trial consisting of home visits by research nurses who assessed participants’ health, discussed their health goals and devised an anticipatory care plan following consultation with participants’ GPs and adjunct clinical pharmacist. As part of the project, we elicited the views and recommendations of experienced key health professionals working with the target population who were recruited using a ‘snowballing technique’ in cooperation with older people health networks in the Republic of Ireland (ROI) and Northern Ireland (NI), United Kingdom [n = 16: 7 ROI, 9 NI]. Following receipt of written information about the intervention and the provision of informed consent, the health professionals were interviewed to determine their expert views on the feasibility of the ACP intervention and recommendations for successful implementation. Data were analyzed using thematic analysis.

Results

The ACP intervention was perceived to be beneficial for most older patients with multimorbidity. Effective and sustainable implementation was said to be facilitated by accurate and timely patient selection, GP buy-in, use of existing structures within health systems, multidisciplinary and integrated working, ACP nurse training, as well as patient health literacy. Barriers emerged as significant work already undertaken, increasing workload, lack of time, funding and resources, fragmented services, and geographical inequalities.

Conclusions

The key health professionals perceived the ACP intervention to be highly beneficial to patients, with significant potential to prevent or avoid functional decline and hospital admissions. They suggested that successful implementation of this primary care based, whole-person approach would involve integrated and multi-disciplinary working, GP buy in, patient health education, and ACP nurse training. The findings have potential implications for a full trial, and patient care and health policy.

Trial registration

Clinicaltrials.gov, ID: NCT03902743. Registered on 4 April 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06896-1.