Pragmatic Trial of Video Education in Nursing Homes (PROVEN)

• Number of hospitalizations/person-days alive among patients >=65 years old who are in a NH >=90 days and who have EITHER advanced dementia or advanced congestive heart failure/chronic obstructive lung disease [ Time Frame: 12-month follow-up period ]
  Number of hospitalizations/person-days alive among patients >=65 years old who are in a NH >=90 days and who have EITHER advanced dementia or advanced congestive heart failure/chronic obstructive lung disease
  
  

• Presence of advance directives: Do Not Hospitalize, Do Not Resuscitate, or no tube-feeding among patients >=65 years old who are in a NH >=90 days and who have EITHER advanced dementia or advanced congestive heart failure/chronic obstructive lung disease [ Time Frame: 12-month follow-up period ]
  Presence of advance directives: Do Not Hospitalize, Do Not Resuscitate, or no tube-feeding among patients >=65 years old who are in a NH >=90 days and who have EITHER advanced dementia or advanced congestive heart failure/chronic obstructive lung disease
  
  
• Burdensome treatments (feeding tubes, parenteral therapy) received among patients >=65 years old who are in a NH >=90 days and who have EITHER advanced dementia or advanced congestive heart failure/chronic obstructive lung disease [ Time Frame: 12-month follow-up period ]
  Burdensome treatments (feeding tubes, parenteral therapy) received among patients >=65 years old who are in a NH >=90 days and who have EITHER advanced dementia or advanced congestive heart failure/chronic obstructive lung disease
  
  
• Presence of advance directives: Do Not Hospitalize, Do Not Resuscitate, or no tube-feeding among patients >=65 years old who are in a NH <90 days and who have EITHER advanced dementia or advanced congestive heart failure/chronic obstructive lung disease [ Time Frame: 12-month follow-up period ]
  Presence of advance directives: Do Not Hospitalize, Do Not Resuscitate, or no tube-feeding among patients >=65 years old who are in a NH <90 days and who have EITHER advanced dementia or advanced congestive heart failure/chronic obstructive lung disease
  
  
• Number of hospitalizations/person-days alive among patients >=65 years old who are in a NH <90 days and who have EITHER advanced dementia or advanced congestive heart failure/chronic obstructive lung disease [ Time Frame: Within 100 days of post-acute care admission ]
  Number of hospitalizations/person-days alive among patients >=65 years old who are in a NH <90 days and who have EITHER advanced dementia or advanced congestive heart failure/chronic obstructive lung disease
  
  
• Hospice enrollment among patients >=65 years old who are in a NH <90 days and who have EITHER advanced dementia or advanced congestive heart failure/chronic obstructive lung disease [ Time Frame: Within 100 days of post-acute care admission ]
  Hospice enrollment among patients >=65 years old who are in a NH <90 days and who have EITHER advanced dementia or advanced congestive heart failure/chronic obstructive lung disease
  
  
• Presence of advance directives: Do Not Hospitalize, Do Not Resuscitate, or no tube-feeding among NH patients >=65 years old who have NEITHER advanced dementia NOR advanced congestive heart failure/chronic obstructive lung disease [ Time Frame: 12-month follow-up period ]
  Presence of advance directives: Do Not Hospitalize, Do Not Resuscitate, or no tube-feeding among NH patients >=65 years old who have NEITHER advanced dementia NOR advanced congestive heart failure/chronic obstructive lung disease
  
  
• Number of hospitalizations/person-days alive among NH patients >=65 years old who have NEITHER advanced dementia NOR advanced congestive heart failure/chronic obstructive lung disease [ Time Frame: 12-month follow-up period ]
  Number of hospitalizations/person-days alive among NH patients >=65 years old who have NEITHER advanced dementia NOR advanced congestive heart failure/chronic obstructive lung disease
  
  
• Hospice enrollment among NH patients >=65 years old who have NEITHER advanced dementia NOR advanced congestive heart failure/chronic obstructive lung disease [ Time Frame: 12-month follow-up period ]
  Hospice enrollment among NH patients >=65 years old who have NEITHER advanced dementia NOR advanced congestive heart failure/chronic obstructive lung disease
  
  

Nursing homes are complex health care systems that serve increasingly sick patients who have advanced comorbid conditions. NHs are often charged with guiding patients through decisions about the direction of their treatment. Patients at NHs commonly get aggressive care that may be inconsistent with their preferences and of little clinical benefit. Identifying effective approaches that NHs can use to better promote goal-directed care and optimize resources is a research, public health, and clinical priority.

Advance care planning is the most consistent modifiable factor associated with better palliative care outcomes. Traditional ACP relies on verbal descriptions of hypothetical health states and treatments. This approach is limited because complex scenarios are difficult to envision, counseling is inconsistent, and verbal explanations are hindered by literacy and language barriers.

To address these shortcomings, the PROVEN project has developed video-assisted ACP decision-support tools that have shown efficacy in small randomized controlled trials. While several large health care systems have begun to adopt the videos, efforts have not rigorously evaluated outcomes—a critical step prior to widespread implementation.

The goal of PROVEN is to conduct a pragmatic cluster-randomized trial to evaluate the effectiveness of the ACP Video Program in the NH setting by partnering with 2 large health care systems that operate 456 nursing homes nationwide. This work has the potential to improve the care provided to millions of older Americans in nursing homes and enable future pragmatic trials in this setting.