BMC geriatrics
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Randomized Controlled Trial
Description of an advance care planning intervention in nursing homes: outcomes of the process evaluation.
Advance Care Planning (ACP) is the repeated communication and decision-making process between the patient, family, and healthcare professionals. This study describes an ACP intervention in nursing homes and evaluates the outcomes of the implementation process. ⋯ Monthly communication with the family was the most frequently conducted communication, and the predefined criteria of successfully implemented ACP were largely achieved. Nursing home routines and engagement of leaders and staff were crucial facilitators, whereas lack of time and competence reduced the implementation success.
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Nurse-led models of comprehensive geriatric assessment and care coordination can improve health management as well as reduce hospitalisations for high risk community dwelling older people. This study investigated the effect on healthcare utilisation of systematic case finding to identify high risk older people in the community with a subsequent comprehensive assessment and care coordination intervention by a Gerontology Nurse Specialist based in primary care. ⋯ This specialist nurse-led intervention involving comprehensive assessment and care coordination care did not appear superior to usual care, however, there is benefit to exploring a more robust randomised controlled trial design.