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J Soc Work End Life Palliat Care. 2019 Jan 17:1-18. doi: 10.1080/15524256.2018.1547673. [Epub ahead of print]

Advance Care Planning in the Nursing Home Setting: A Practice Improvement Evaluation.

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a Department of Family Practice , University of British Columbia , Vancouver , British Columbia , Canada.
b Family Practice Research Office , Vancouver Coastal Health Research Institute's Centre for Clinical Epidemiology and Evaluation , Vancouver , British Columbia , Canada.
e Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada.
c Practice Support Program, General Practice Services Committee , Government of British Columbia and Doctors of British Columbia , Vancouver , British Columbia , Canada.
d Health Research Consultant , Balfour , British Columbia , Canada.


This study evaluated a practice improvement initiative conducted over a 6 month period in 15 Canadian nursing homes. Goals of the initiative included: (1) use the Plan-Do-Study-Act (PDSA) model to improve advance care planning (ACP) within the sample of nursing homes; (2) investigate whether improved ACP practice resulted in a change in residents' hospital use and ACP preferences for home-based care; (3) engage participating facilities in regular data collection to inform the initiative and provide a basis for reflection about ACP practice and; (4) foster a team-based participatory care culture. The initiative entailed two cycles of learning sessions followed by implementation of ACP practice improvement projects in the facilities using a PDSA approach by participating clinicians (e.g., physicians, social workers, nurses). Clinicians reported significantly increased confidence in many dimensions of ACP activities. Rates of hospital use and resident preference for home-based care did not change significantly. The initiative established routine data collection of outcomes to inform practice change, and successfully engaged physicians and non-physician clinicians to work together to improve ACP practices. Results suggest recurrent PDSA cycles that engage a 'critical mass' of clinicians may be warranted to reinforce the standardization of ACP in practice.


Clinical improvement; Plan-Do-Study-Act; Advance Care Planning; nursing home; quality of care; health services research; palliative care; end of life; learning systems; nursing home

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