Advance Care Planning for Older Homeless Adults

(ACP-PSH Trial)

Recruiting at 5 trial locations

Overseen By Brenda Goldstein

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: University of California, San Francisco

Disqualifiers: Cognitive impairment, Deaf, Blind, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: 4

650 Participants Needed

Trial Summary

Do I need to stop my current medications for this trial?

The trial information does not specify whether you need to stop taking your current medications.

What data supports the effectiveness of the treatment Facilitated Group ACP Session for older homeless adults?

Research shows that facilitated advance care planning (ACP) interventions are effective in increasing ACP uptake and satisfaction among patients with severe illnesses, and they help family carers be more involved in decision-making and reduce their stress. This suggests that similar benefits might be seen in older homeless adults participating in facilitated group ACP sessions. ^{1 2 3 4 5}

Is advance care planning safe for older homeless adults?

Advance care planning (ACP) is generally considered safe for older adults, including those who have experienced homelessness. Studies show that ACP is feasible and acceptable, with participants expressing satisfaction and no significant safety concerns reported. ^{1 2 5 6 7}

How is the treatment 'Facilitated Group ACP Session' unique for older homeless adults?

This treatment is unique because it involves facilitated group and one-on-one sessions specifically tailored to older homeless adults, addressing barriers like social isolation and lack of familial ties by providing a supportive environment to discuss and document their care preferences. ^{2 6 7 8 9}

What is the purpose of this trial?

The homeless population is aging, with an increasing proportion of individuals over age 50 who experience accelerated aging, high rates of mortality, and a high risk of not having their wishes honored at the end of life. The goal of this randomized control trial (RCT) is to test the effectiveness of adapted evidence-based advance care planning (ACP) interventions for formerly chronically homeless older adults living in permanent supportive housing (PSH).

Research Team

Margot Kushel, MD

Principal Investigator

University of California, San Francisco

Rebecca Sudore, MD

Principal Investigator

University of California, San Francisco

Eligibility Criteria

This trial is for formerly chronically homeless individuals over age 50 who now live in permanent supportive housing. It aims to ensure their end-of-life wishes are respected. Participants must be capable of making decisions and providing consent.

Inclusion Criteria

English speaking

Formerly chronically homeless adults living in permanent supportive housing

Exclusion Criteria

Non-English Speaking

Screen positive for moderate-to-severe cognitive impairment

I am deaf or blind.

Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Co-development

Co-development of PREPARE-PSH through in-depth interviews and focus groups with PSH residents and the Community Advisory Board

Not specified

Multiple visits (in-person and virtual)

Intervention

Participants attend a one-time 90-minute ACP session, either one-on-one or in a group, to review the PREPARE program

1 session

1 visit (in-person)

Follow-up

Participants are monitored for ACP engagement and adverse outcomes at 3 and 6 months

6 months

Follow-up assessments at 3 and 6 months

Treatment Details

Interventions

• Facilitated Group ACP Session
• Facilitated one-on-one ACP visits

Trial Overview The study tests two methods of advance care planning: group sessions and one-on-one visits, both facilitated by professionals. The goal is to see which method better helps participants plan for end-of-life care.

Participant Groups

Group I: Facilitated one-on-one ACP visits Active Control 1 Intervention

Participants in the one-on-one ACP visit arm will attend a one-time 90-minute ACP session with a facilitator where they will review the movie version of the PREPARE program (about how to choose a medical decision maker and how to decide what matters most in life), including a new PSH-specific video and PREPARE easy-to-read ADs with the new PSH-specific content and cover letters.

Group II: Facilitated Group ACP Session Active Control 1 Intervention

Participants in the group ACP visit arm will attend a one-time 90-minute facilitated group ACP session where they will review the movie version of the PREPARE program (about how to choose a medical decision maker and how to decide what matters most in life), including a new PSH-specific video and PREPARE easy-to-read ADs with the new PSH-specific content and cover letters.

Who Is Running the Clinical Trial?

University of California, San Francisco

Lead Sponsor

Trials

2,636

Recruited

19,080,000+

National Institute on Aging (NIA)

Collaborator

Trials

1,841

Recruited

28,150,000+

Findings from Research

A study involving 20 semi-structured interviews with patients and caregivers showed that a facilitated advance care planning (ACP) intervention was well-received, with participants finding it clear and tailored to their needs.

Patients receiving the facilitated ACP reported significantly less difficulty in completing their ACP compared to those receiving standard care, suggesting that integrating facilitated ACP into outpatient settings is both feasible and beneficial for individuals with advanced illnesses.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Feasibility and Acceptability of Facilitated Advance Care Planning in Outpatient Clinics: A Qualitative Study of Patient and Caregivers Experiences. Marshall, KH., Riddiford-Harland, DL., Meller, AE., et al.[2023]

Community-led approaches to Advance Care Planning (ACP) workshops emphasize the importance of conversations about living well rather than just completing legal forms, which can enhance public engagement.

Facilitators and participants in these workshops report benefits for both groups, including increased volunteer engagement and stronger community partnerships, suggesting that hospice societies can effectively promote ACP in their communities.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

"Now I get what's important" - Shifting philosophies of hospice society staff and trained volunteers involved in peer-facilitated Advance Care Planning workshops for the public. Mróz, LL., Soheilipour, S., Siden, E., et al.[2023]

A nurse-led facilitated advance care planning (ACP) intervention for patients with severe respiratory disease did not improve self-reported satisfaction, health-related quality of life, or 12-month mortality rates among the 149 participants studied.

However, the intervention was associated with fewer outpatient consultations and a reduced length of stay in acute hospital settings, suggesting a shift in healthcare utilization patterns during the final 90 days of life.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Impact of a Nurse-Led Advance Care Planning Intervention on Satisfaction, Health-Related Quality of Life, and Health Care Utilization Among Patients With Severe Respiratory Disease: A Randomized Patient-Preference Trial. Sinclair, C., Auret, KA., Evans, SF., et al.[2021]

The ACTION Respecting Choices advance care planning intervention did not significantly improve family carers' involvement in decision making during the last three months of a patient's life, although there was a slight increase in involvement in the intervention group (89.6% vs 86.7%).

There was no significant difference in psychological distress between family carers in the intervention and control groups after three months of bereavement, indicating that the ACP intervention did not reduce psychological stress as intended.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Advance care planning-family carer psychological distress and involvement in decision making: the ACTION trial. Vandenbogaerde, I., De Vleminck, A., Cohen, J., et al.[2022]

The structured advance care planning (ACP) program significantly improved the concordance rates for patients' final wishes, achieving 95% for quality of life and 100% for end-of-life and funeral arrangements among participants.

Patients in the ACP program experienced fewer acute admissions and shorter hospital stays in their last three months of life, indicating reduced healthcare utilization compared to those who did not participate in the program.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Impact of structured advance care planning program on patients' wish items and healthcare utilization. Chan, KY., Chiu, HY., Yap, DYH., et al.[2021]

In a 14-month study involving homeless patients aged 45 and older, advance care planning (ACP) discussions were successfully conducted with 48% of participants, highlighting the feasibility of integrating ACP into primary care for this population.

Among those who engaged in ACP, 91% appointed a healthcare proxy, although 38% were unable to do so and were left without a designated surrogate, indicating a need for targeted support in decision-making for vulnerable individuals.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Feasibility of Advance Care Planning in Primary Care for Homeless Adults. Kaplan-Weisman, L., Sansone, S., Walter, E., et al.[2022]

Older homeless-experienced adults recognize the importance of advance care planning (ACP) but face significant barriers such as lack of knowledge, social isolation, and competing life priorities, as identified in interviews with 20 participants.

Solutions proposed to improve ACP engagement include providing tailored, easy-to-read materials, initiating discussions in supportive housing environments, and framing ACP as a way to assert personal choice, highlighting the need for interventions outside traditional healthcare settings.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Barriers and Solutions to Advance Care Planning among Homeless-Experienced Older Adults. Kaplan, LM., Sudore, RL., Arellano Cuervo, I., et al.[2022]

Older adults in permanent supportive housing (PSH) have low rates of advance care planning (ACP), but rehousing may provide a unique opportunity to introduce ACP, as indicated by interviews with 26 residents and 13 staff members.

Barriers to ACP included its complexity and resource limitations, while facilitators included the stability of housing and the belief in the importance of ACP, suggesting that tailored materials and staff training could enhance ACP engagement in this population.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Using behavioral theory to adapt advance care planning for homeless-experienced older adults in permanent supportive housing. Pajka, SE., Kushel, M., Handley, MA., et al.[2023]

Individuals in Japan with informal caregiving experience are nearly twice as likely to engage in advance care planning (ACP) discussions compared to those without such experience, indicating a strong association between caregiving and ACP.

Younger adults (ages 20-65) and those with higher education levels showed even stronger associations with ACP discussions, suggesting that these factors may enhance the likelihood of initiating important end-of-life care conversations.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Experience as an Informal Caregiver and Discussions Regarding Advance Care Planning in Japan. Miyashita, J., Shimizu, S., Azuma, T., et al.[2021]

References

1. United States pubmed.ncbi.nlm.nih.gov

Feasibility and Acceptability of Facilitated Advance Care Planning in Outpatient Clinics: A Qualitative Study of Patient and Caregivers Experiences. [2023]

2. Ireland pubmed.ncbi.nlm.nih.gov

"Now I get what's important" - Shifting philosophies of hospice society staff and trained volunteers involved in peer-facilitated Advance Care Planning workshops for the public. [2023]

3. United States pubmed.ncbi.nlm.nih.gov

Impact of a Nurse-Led Advance Care Planning Intervention on Satisfaction, Health-Related Quality of Life, and Health Care Utilization Among Patients With Severe Respiratory Disease: A Randomized Patient-Preference Trial. [2021]

4. England pubmed.ncbi.nlm.nih.gov

Advance care planning-family carer psychological distress and involvement in decision making: the ACTION trial. [2022]

5. China pubmed.ncbi.nlm.nih.gov

Impact of structured advance care planning program on patients' wish items and healthcare utilization. [2021]

6. United States pubmed.ncbi.nlm.nih.gov

Feasibility of Advance Care Planning in Primary Care for Homeless Adults. [2022]

7. United States pubmed.ncbi.nlm.nih.gov

Barriers and Solutions to Advance Care Planning among Homeless-Experienced Older Adults. [2022]

8. United States pubmed.ncbi.nlm.nih.gov

Using behavioral theory to adapt advance care planning for homeless-experienced older adults in permanent supportive housing. [2023]

9. United States pubmed.ncbi.nlm.nih.gov

Experience as an Informal Caregiver and Discussions Regarding Advance Care Planning in Japan. [2021]