TABLE 1.

Application of the Consolidated Framework for Implementation Science 2.0 to advance care planning.

ADVANCE CARE PLANNING INNOVATION
● Advance care planning (ACP) design: How assembled and presented  For patients and caregivers:  – Education modalities: written, video, online, group visits, narratives  – Media, EMR patient portals, and other outreach materials and technologies  – Legal forms, for example, advance directives & POLST  – Healthcare and community-based navigators, dedicated ACP teams  – Community events and engagement  – Medical-legal partnerships  For clinicians and staff:  – Training materials and protocols  – Conversation guides  – Health record ACP templates ● Other important considerations: reliable source, evidence base, relative advantages, adaptability, trialability, complexity, cost
OUTER SETTING
● Critical incidents: for example, pandemics ● Local attitudes: Community and cultural/societal norms about ACP; systemic and structural racism ● Local conditions: State politics and policies; available ACP EHR infrastructure; health information exchanges, emergency response systems ● Partnerships: Professional organizations, insurers, and health systems ● Policies and Laws: Legislation on AD/POLST, guidelines, accreditation ● Financing: CMS/insurance reimbursement, granting agencies ● Societal Pressure: Media campaigns, advocacy groups ● Market Pressure: Competing health systems to offer ACP ● Performance Measurement Pressure: Quality metrics
INNER SETTING
● Structural characteristics  ○ Physical space, staff, clinical time for ACP  ○ EMR IT infrastructure for ACP documentation, storage, and retrieval  ○ Defined ACP policies, workflows, roles/responsibilities ● Relational Connections/Communication  ○ Between leadership, disciplines, clinical settings, the community ● Culture  ○ Health system readiness to implement ACP  ○ Support for patient-centered care  ○ Anti-racism policies and practices  ○ Learning-centeredness and use of data for ACP quality improvement ● Mission alignment with current workflows, systems, and priorities ● Available resources (e.g., ACP reimbursement rates, incentives, materials, training)
INDIVIDUALS
● Leaders: Key decision-makers about ACP policies (e.g., executive leadership, supervisors) ● Opinion leaders and key informants (e.g., community, patient, caregiver advisory boards) ● Implementation Facilitators/Leads/Team Members (e.g., clinical champions, community collaborators) ● Innovation deliverer (e.g., interdisciplinary clinicians, setting, beliefs, attitudes, training) ● Innovation recipient (e.g., patients, caregivers, clinicians): Based on the Capability, Opportunity, Motivation (COM-B) Model for Behavior Change  ○ Health literacy, language proficiency, digital literacy, cognitive impairment  ○ Access to understandable health education materials and training  ○ Patient and caregiver readiness to engage in ACP  ○ Type of illness (e.g., cancer, frailty, organ failure)  ○ Life and/or disease trajectory  ○ Unique and differing cultural and family backgrounds and experiences  ○ Experiential racism and justified mistrust in the health system
IMPLEMENTATION PROCESS
● Teaming: Coordinating and collaborating with key individuals across disciplines and settings, securing resources, standardized workflows and roles and responsibilities to deliver the ACP innovation ● Assessing Needs: Collecting priorities, preferences of ACP innovation recipients and deliverers (e.g., patient/caregiver qualitative input, obtaining clinician buy-in, etc.) ● Assessing Context: Barriers and facilitators to ACP ● Tailoring Strategies: To address barriers and facilitators to ACP ● Engaging: Attract and encourage participation through appropriate ACP messaging and marketing ● Doing: Cycles of quality improvement and/or trials to optimize ACP delivery (e.g., creating processes to identify appropriate populations, etc.) ● Reflecting and Evaluating: Qualitative and quantitative information about the ACP innovation and implementation from patients, caregivers, clinicians ● Adapting: Modify the ACP innovation or the inner setting for optimal fit and integration of ACP innovation into workflows