# Difference‐Makers for Robust Implementation of a Nursing Home Advance Care Planning Embedded Pragmatic Clinical Trial

## TL;DR

This study identifies key factors that help implement a successful advance care planning program in nursing homes using a new analytical method.

## Contribution

The study introduces Coincidence Analysis as a novel method to identify conditions for robust implementation in nursing home clinical trials.

## Key findings

- Leadership stability and peer engagement were linked to successful implementation of the ACP program.
- High administrator turnover and lack of peer calls were associated with poor implementation outcomes.
- Facilities with fewer certified beds and higher baseline hospitalization rates had better implementation success.

## Abstract

Embedded pragmatic clinical trials are an ideal way to develop and evaluate evidence‐based interventions in the nursing home (NH) environment to facilitate streamlining implementation after study completion. However, there is minimal information available about the necessary and sufficient conditions of “difference makers” for robust implementation of pragmatic interventions in the NH setting.

The “Aligning Patient Preferences—a Role Offering Alzheimer's patients, Caregivers, and Healthcare Providers Education and Support” (APPROACHES) embedded pragmatic trial is designed to test and evaluate a staff‐led advance care planning (ACP) intervention for residents with dementia in 128 NHs (64 intervention, 64 control). Coincidence Analysis, a case‐based approach to data analysis that draws upon Boolean algebra and set theory, was applied to identify key difference‐makers for robust implementation. This analysis focused on the 44 intervention NHs that implemented at least one of two implementation processes: site visits and/or monthly calls.

Eighteen of 44 (41%) sites in the analysis robustly implemented the APPROACHES intervention as reflected by > 75% of residents having a documented ACP conversation. The Coincidence Analysis revealed two pathways directly linked with robust pragmatic implementation: (1) no executive director turnover during the observation period combined with site participation in monthly calls with peers; and (2) higher rates of baseline hospitalization (3.96–7.0 per 1000 resident‐days alive) combined with a low number of certified beds. In contrast, leadership instability as reflected by administrator turnover, high number of certified beds, and a lack of participation in monthly calls with peers was associated with poorer performance.

Findings from this study suggest that leadership stability and engagement with peers were essential drivers of robust implementation of the APPROACHES ACP Specialist intervention. Coincidence Analysis is a useful tool for understanding how implementation conditions are associated with robust implementation in embedded pragmatic clinical trials.

Key Points○Coincidence Analysis is a newer methodology that is ideally suited to explore implementation conditions associated with outcomes in embedded pragmatic clinical trials.○Implementation conditions associated with successful implementation of the ACP Specialist Program in nursing homes include leadership stability and engagement with peers.○Leadership instability as reflected by nursing home administrator turnover, a high number of certified beds representing a higher caseload, and a lack of participation in monthly calls with peers was associated with poorer implementation of the ACP Specialist Program.
Why this study is important○Understanding the conditions needed to successfully implement programs in nursing homes like this systematic advance care planning program through novel methodologies like Coincidence Analysis is of importance to researchers designing studies in this setting as well as policymakers or health system leaders encouraging uptake of evidence‐based programs.

Key Points○Coincidence Analysis is a newer methodology that is ideally suited to explore implementation conditions associated with outcomes in embedded pragmatic clinical trials.○Implementation conditions associated with successful implementation of the ACP Specialist Program in nursing homes include leadership stability and engagement with peers.○Leadership instability as reflected by nursing home administrator turnover, a high number of certified beds representing a higher caseload, and a lack of participation in monthly calls with peers was associated with poorer implementation of the ACP Specialist Program.

Coincidence Analysis is a newer methodology that is ideally suited to explore implementation conditions associated with outcomes in embedded pragmatic clinical trials.

Implementation conditions associated with successful implementation of the ACP Specialist Program in nursing homes include leadership stability and engagement with peers.

Leadership instability as reflected by nursing home administrator turnover, a high number of certified beds representing a higher caseload, and a lack of participation in monthly calls with peers was associated with poorer implementation of the ACP Specialist Program.

Why this study is important○Understanding the conditions needed to successfully implement programs in nursing homes like this systematic advance care planning program through novel methodologies like Coincidence Analysis is of importance to researchers designing studies in this setting as well as policymakers or health system leaders encouraging uptake of evidence‐based programs.

Understanding the conditions needed to successfully implement programs in nursing homes like this systematic advance care planning program through novel methodologies like Coincidence Analysis is of importance to researchers designing studies in this setting as well as policymakers or health system leaders encouraging uptake of evidence‐based programs.