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Table 1 Key Implementation and evaluation activities of HIGHway project

From: Implementing Advance Care Planning for dialysis patients: HIGHway project

Intervention

Activity

Implementation of each intervention

 Resources

• Provide a resource-rich app that allows teams to easily access advance care planning and kidney supportive care tools

• Through app: guide workflow for advance care planning and follow up

 Training

• Provide video conference training:

6 h for social worker or nurse in role of advance care planning “coach” with patients (3 sessions of 2 h each over course of 6 weeks.)

• Provide 6 h of social work CE for participation in training

 Ongoing supervision

• Provide monthly mentoring/supervision group on-line for social workers and nurses. Use a case-based approach to build skills in advance care planning

 Ongoing progress reports

• If site is using app for phone, iPad, or desktop, provide function on app to facilitate tracking and reporting completed conversations

• In the alternative, social worker or nurse responds to short weekly email survey with 4 questions to capture ACP

 Quality check of ACP discussions

• Faculty review recording and provide feedback to social worker/nurse on recorded ACP sessions

• Provide constructive criticism and coaching to improve discussions

Evaluation after intervention

 Patient Mail-in Survey

• Provide IRB approved survey link and/or hard copy for mailing to be handed to patients who participate in ACP discussions

 Social Worker/Nurse Online Survey

• Evaluation of training sessions includes both pre and post evaluation questions for comparison

• Provide social worker survey (on-line) to evaluate participation in program, extent to which have adopted into ongoing workflow, identify facilitators and barriers, and assess future sustainability