Life In The Slower Lane

Here is the standardised PICO analysis for the thirty-eighth uploaded article:

---

Full Title

Implementation of Goals of Care Communication Innovation Among Nursing Homes: A Multiple Case Study Design

Authors: Latarsha Chisholm, Laura C. Hanson, Sheryl Zimmerman, et al.

Journal: Journal of the American Medical Directors Association, 2022; 23(7): 1215–1220

DOI: 10.1016/j.jamda.2021.07.038

---

Type of Study

Multiple case study design nested within a cluster-randomised controlled trial examining implementation outcomes of an advance care planning (ACP) intervention in 11 U.S. nursing homes

---

PICO Summary

Population (P)

• Nursing homes (n=11) participating in the intervention arm of a larger ACP trial
• Residents: people with late-stage dementia
• Participants included interdisciplinary NH staff teams (nurses, social workers, therapy staff) involved in care planning discussions with family members

Intervention (I)

Goals of Care (GOC) Intervention, including:

1. Video decision aid shown to family decision-makers
2. Structured care plan meetings between family and NH care team
3. Staff support via on-site training, fidelity monitoring, and management engagement

Measured using:

• Implementation effectiveness (consistency + quality of GOC delivery)
• Implementation climate (staff perceptions)
• Management support
• Facility resources (Medicare beds, staff hours, racial mix, NH star rating)

Comparison (C)

• No formal comparator group in this sub-study
• Implementation outcomes were analysed across and within nursing homes, comparing characteristics between high vs low implementation effectiveness sites

Outcomes (O)

Primary outcome:

• Implementation effectiveness, defined as:
  • Number of core components delivered (video, care meeting, documented goal-setting)
  • Family-reported quality of GOC discussions (respect, attention to emotions, encouragement to ask questions)
  • Scores ranged from 0–13; mean was 10.8 (SD 0.9)

Secondary outcomes and explanatory factors:

• High management support and facility resources (Medicare beds, size, higher star rating) aligned with greater implementation effectiveness
• Implementation climate (staff perceptions of support) was moderately correlated but less predictive than management and structural factors
• Racial composition: Facilities with higher proportions of White residents more frequently achieved high implementation effectiveness 

---

Findings Summary

This study reveals that management support, facility resources (especially Medicare revenue and size), and higher NH quality ratings were most consistently associated with successful implementation of ACP interventions. Despite variation in implementation climate scores, structural enablers and leadership engagement were stronger predictors of consistent and high-quality GOC delivery.

The findings underscore the importance of:

• Leadership buy-in and staff champions
• Aligning innovations with existing NH culture
• Providing adequate financial and educational support
• Adjusting implementation strategies for facilities with fewer resources

This research informs strategies for scaling up ACP programs in long-term care by highlighting the enabling conditions necessary for sustained uptake and fidelity.

---