Table 1 Summary of the ACP+ programme using the Template for intervention description and replication (TIDieR) checklist [18]

1

BRIEF NAME (name or a phrase that describes the intervention)

The intervention is called “The ACP+ programme” (Dutch: “Het VZP⁺ programma”) and has been developed to implement and improve advance care planning in routine care practice in nursing homes in Flanders, Belgium.

2

WHY (any rationale, theory, or goal of the elements essential to the intervention)

Research shows that only a minority of older people actively engage in ACP, and that there is still a low prevalence of ACP in Flemish nursing homes [6, 19]. Nonetheless, a majority of the growing population of older people would appreciate an opportunity for such discussions and planning [20, 21]. The overall aim of ACP is to improve quality of care, quality of life and quality of dying of residents in nursing homes in Flanders. The theoretical model which was developed in the first phase of intervention development additionally provides a rationale for the individual elements essential to the intervention. This Theory of Change map is reported elsewhere [10].

3

WHAT Materials (any physical or informational materials used in the intervention, including those provided to participants or used in intervention delivery or in training of intervention providers)

17 intervention materials are provided to support delivery of the ACP+ programme:

1. Manual for the ACP Trainer, highlighting key issues of the ACP+ programme and guidance for ACP Trainer to perform his/her tasks

2. Information guide for nursing home management, highlighting key issues and challenges of ACP, explaining ACP+, how it should be implemented, what everyone’s roles are and how they should carry out all the steps within the ACP+ programme

3. Tailoring checklist, including information per intervention activity about the minimum of elements that should be held constant over all nursing homes and which elements can be adapted to each nursing home routines

4. Training manual for two-day training of ACP Reference Persons including educational materials for the ACP Trainer to be used in training

5. ACP manual for ACP Reference Persons including all materials that can be used in the implementation and organization of all intervention activities of the ACP+ program

6. Summary list on which nursing home staff notes all residents and their loved ones, that are eligible for an ACP conversation. This list provides an overview of who scheduled a planned ACP conversation and when.

7. Invitation letter for residents and family, inviting them to participate in information session about ACP

8. ACP information brochure for residents and family

9. Invitation letter for GPs, inviting them to participate in information session about ACP

10. ACP iormation brochure for professionals

11. Training manual for ACP Reference Persons to train other nursing home staff

12. ACP Conversation Guide providing information about initiating and preparing ACP conversations. The guide is structured as follows: A) ideas about a good life and discussing broader views and values (e.g. “What makes your life meaningful?”); B) preferences for current care (“What makes you worry?”), C) the importance of ACP (“Have you ever thought about what kind of care you would want (or not) in case you would be too sick to tell it yourself?”); D) shared care goals (e.g. “Do you feel it is important to make your own decisions with regards to your care? What do you feel is more important: quality of life or living as long as possible, not matter what?”); E) surrogate decision-maker/representative (e.g. in case you were too sick to make your own decisions regarding care, who do you trust to make medical decisions instead?”); F) documenting preferences, including advance directives; G) Place of death; H) other preferences (e.g. “Do you have other wishes that we can take into account?”); I) wishes regarding death (e.g. “Do you prefer to have specific rituals?”); J) revising preferences (e.g. “Under which circumstance would you like to definitely revisit your wishes?”). The conversation guide starts by exploring the broader views of the person and wishes regarding? Current care, and subsequently focuses on future care and end of life and dying.

13. ACP Conversation Tool, a short A4 document that staff can use during ACP conversations. It includes probe questions and brief conversation guidelines following the same structure as the full conversation guide.

14. ACP Document to document outcomes of ACP conversation(s); that can also be used as a transfer document to accompany the resident when transferring between care settings (e.g. ICU).

15. Standardised advance directives

16. Guideline about ACP in dementia for professionals working with people living with dementia [22]

17. ACP audit instrument

4

WHAT Procedures (each of the procedures, activities, and/or processes used in the intervention, including any enabling or support activities)

The ACP+ programme entails 10 intervention components that can be carried out via 22 intervention activities:

As part of ‘ACP Trainer’ component (1)

Activity 1: Selection and preparation of two ACP (external) Trainers

Activity 2: ‘Shadowing’. During the first four months, the trainer follows the selected ACP Reference Persons in their daily job to get familiar with the aspects related to the nursing home, certain routines and ACP-related activities that are already in place

As part of ‘Buy-in management’ component (2)

Activity 3: Meeting(s) between the ACP Trainer and the nursing home management, representatives of the board of directors, head nurses and the coordinating advisory physician† to explain the project and ask management for their (active) participation (including integrating ACP in the general policy of the nursing home and ensuring staff is able to spend time on their tasks to implement and organize the ACP+ programme and ACP in general, within the routine care). During this meeting they suggest nursing home staff eligible to function as ACP Reference Person‡ (in consultation with staff themselves)

Activity 4: Follow-up meetings between management, other decision-makers, ACP Reference Persons and the ACP Trainer.

As part of ‘tailoring’ component (3)

Activity 5: Tailoring-meeting(s) between ACP Reference Persons, management and important decision-makers‡ about how to fit the implementation of the ACP+ programme to routines

As part of ‘ACP Reference Persons’ component (4)

Activity 6&7: Two-day interactive training (session 1 and 2) for the ACP Reference Persons

Activity 8: Come-back seminar for all ACP Reference Persons

As part of ‘information about ACP’ component (5)

Activity 9: Information (session(s)) for all residents and their families about ACP in the nursing home during a format that is ‘tailored’ to routines in the specific nursing home setting (e.g. resident/family council, individually, exceptional information session)

Activity 10: Information session(s) for all GPs about ACP in the nursing home, including motivating them to consider the wishes and preferences of their patients in (end-of-life) decision-making and to engage in ACP of their patients. GPs are invited to an information session after 5 p.m., accreditation can be arranged.

As part of ‘in-house training’ component (6)

Activity 11&12: In-house 2-h training sessions (session 1 & 2) to train ‘ACP Conversation Facilitators’ in performing ACP conversations

Activity 13: In-house 1,5-h training session to train ‘ACP Antennas’ to educate them how to recognize triggers in residents and family, so they are more willing to have spontaneous ACP conversations according to their competencies and so they know how to pass on information to other staff

As part of the ACP planned conversation(s) (7)

Activity 14: Exploration of earlier wishes and GP involvement.

Activity 15: First planned ACP conversation with resident and family

Activity 16: ACP follow-up conversation(s)

Activity 17: Documentation of wishes and preferences

As part of ‘information transfer’ component (8)

Activity 18: Integration of ACP into multidisciplinary meetings so information is shared across professionals in the nursing home

As part of ‘coaching’ component (9)

Activity 19: One-to-one coaching on request, by ACP Trainer to nursing home staff

Activity 20: In-house specialization session 1 (at least 2 hrs): Dementia

Activity 21: In-house specialization session 2 (at least 2 hrs): Communication with other healthcare professionals

As part of ‘audit’ component (10)

Activity 22: ACP audit meeting(s) to discuss ACP procedures with all involved healthcare professionals, the coordinating advisory physician and the management to identify problems and discuss action plans for improvement

5

WHO PROVIDED (intervention provider, their expertise, background and any specific training given)

- ACP Trainers will be available to support nursing homes in implementing ACP into routine care. These trainers are skilled and experienced in change management, have clinical practice experience in nursing homes and in performing ACP conversations. They are able to train other professionals. Their support decreases as nursing homes become more autonomous in organising ACP.

- ‘ACP Reference Persons’ are professionals employed by the nursing home who have roles in daily resident care (e.g. head nurses, team coordinators, nurses, palliative care reference persons, reference persons for dementia, psychologists, members of the palliative (support or care) team/working group). The ACP Reference Persons’ main responsibility is to implement and sustain ACP within the nursing home. They market the program, communicate the high priority for nursing home residents, provide education (to ACP Conversation Facilitators and ACP Antennas), conduct ACP conversations with residents and/or family, and perform regular monitoring to audit advance care planning processes, structures and outcomes within the nursing home.

- ‘ACP Conversation Facilitators’ or other (head) nurses, palliative care reference persons, reference persons for dementia, psychologists, social workers, care assistants, pastoral or spiritual caregivers, moral consultants and members of the palliative (support or care) team/working group that are willing. These trained conversation facilitators are - together with ACP Reference Persons - responsible for planning and performing regular manualized ACP conversations with residents and/or family.

- ‘ACP Antennas’ are all others. This is usually staff that do not necessarily provide resident care but do have daily contact with residents and/or family (e.g. care assistants, hair dressers, cleaning staff, administrative staff, volunteers, ...). They will receive a short training in a much easier formulae in recognizing and signalling triggers that can signal the person is ready or willing to engage in ACP.

6

HOW (modes of delivery)

All intervention activities are provided face-to-face, individually, in duo or in groups with a maximum of 15 participants.

7

WHERE (the type(s) of location(s) where the intervention occurred, including any necessary infrastructure or relevant features)

The intervention is meant to improve ACP in nursing homes in Flanders (Belgium). These nursing homes are skilled nursing care facilities where older adults reside who have problems with activities of daily living and/or physical and cognitive functioning [23]. Most residents are still supervised by their GP but since 2000, each nursing home is legally obliged to have a coordinating advisory physician, a GP, preferably trained in gerontology whose tasks include among others, consultancy and conflict mediation in palliative care situations. In addition, nursing homes must cooperate with the geriatric service of the regional hospital and a specialized service of palliative care [24].

The two-day training for the ACP Reference Persons is organised across all nursing homes in a geographically central location. The other training and information sessions are organised in-house. ACP conversations or meetings can be held in a private room in the nursing home.

8

WHEN and HOW MUCH (the number of times the intervention was delivered and over what period of time including the number of sessions, their schedule, and their duration, intensity or dose)

ACP+ should be implemented over the course of 8 months and includes a thorough preparatory or training phase (month 1 to 4) and a follow-up phase (month (5 to 8). Information and training sessions vary from 1 h to two days, depending on the type. ACP conversations are known to vary between 60 and 240 min [25].

9

TAILORING (if the intervention was planned to be personalized, titrated or adapted, then describe what, why, when, and how)

To maximize the fit between individual nursing home needs and ACP+, participating nursing homes have the opportunity, in consultation with the trainer, to choose how they operationalize some activities (e.g. how to fit intervention activities into existing work schedules (e.g. training during lunch, information session for GPs in the evening), how activities are routinely discussed (formally and informally, e.g. through posters, meetings, family council), who needs to be involved in decision-making and how proposed materials can be entered into existing electronic systems).