Table 2.

Intervention components

Core activities	Optional activities
Direct care level
Implementation of a structured care plan Structured conversations with residents and relatives Case conferences Joint visits with physicians Hospital visits Geriatric assessments Pain management	Short checklist for external care providers (residents’ essential information)
Organisational level
Introduction of ISBAR for handovers and communication with general practitioners Nurse led staff training on ISBAR Monitoring of residents’ advance care planning status	Nursing research activities Supervision and consultation for colleagues

ISBAR, Structure for interprofessional communication consisting of Identification, Situation, Background, Assessment, Recommendation.