Here is the standardised PICO analysis for the forty-eighth uploaded article:
Full Title
Advance Directives in the Nursing Home Setting: An Initiative to Increase Completion and Reduce Potentially Avoidable Hospitalizations
Authors: Colleen Galambos, Marilyn Rantz, Lori Popejoy, Bin Ge, Greg Petroski
Journal: Journal of Social Work in End-of-Life & Palliative Care, 2021; 17(1): 19–34
DOI: 10.1080/15524256.2020.1863895
Type of Study
Quasi-experimental evaluation (pre–post analysis) embedded in a CMS Innovations demonstration project (Missouri Quality Initiative – MOQI)
PICO Summary
Population (P)
- Residents of 16 skilled nursing facilities (SNFs) in the St. Louis, Missouri region
- N = 1,563 long-stay residents (≥30 days stay) included in the hospitalisation analysis
- Majority female (66%), white (88%), mean age 79 years
Intervention (I)
Advance Directive (AD) Implementation Program as part of the MOQI project, including:
- Staff and clinician education on AD and ACP
- Role-play and coaching for clinical discussions
- Development of AD policies and EHR-integrated documentation
- Stakeholder and community engagement
- Resident and family-specific ACP discussions and community AD awareness events
Comparison (C)
- Baseline data from 2013–2016, including comparisons between residents with vs. without ADs
- Logistic regression adjusted for facility clustering and resident length of stay
Outcomes (O)
Primary outcomes:
- AD completion rates:
- 2013: 49% of charts had documented ADs
- 2015: 97%
- 2016: 90%
- Statistically significant increases sustained over the 4-year intervention period
- Hospital transfers:
- Residents without an AD were 29% more likely to be transferred to hospital compared to those with an AD
- Odds Ratio: 1.29 (95% CI: 1.03–1.62, p = .0267)
Findings Summary
The intervention successfully:
- Increased AD documentation and integration into care routines
- Encouraged routine ACP discussions using a team-based model (APRN + social worker)
- Built a culture of normalised ACP practices
- Engaged residents, families, and the broader community through sustained education
Importantly, the presence of an AD was associated with fewer potentially avoidable hospitalisations, supporting the role of early ACP in promoting goal-concordant care.
Sustainability mechanisms included:
- EHR modifications (e.g., AD banners)
- Policy development and adoption
- Community-wide awareness campaigns (e.g., National Healthcare Decisions Day)
Conclusion
This project demonstrates that a structured, interdisciplinary ACP and AD implementation model can improve documentation rates and reduce hospital transfers. The study highlights the pivotal role of social workers and nurse-led facilitation, policy alignment, and community engagement in creating lasting systems change in end-of-life planning in nursing home settings .
Life In The Slower Lane 
Leave a comment