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

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial ensures that older adults who were once chronically homeless have their healthcare wishes respected at the end of their lives. It tests two methods to assist these individuals in planning their future care: facilitated one-on-one Advance Care Planning (ACP) visits and facilitated group ACP sessions. Both options teach participants how to select someone to make medical decisions for them and identify what matters most in their healthcare choices. Suitable candidates are English-speaking adults who were chronically homeless and now reside in permanent supportive housing. As an unphased trial, this study provides a unique opportunity to contribute to research that could enhance end-of-life care planning for vulnerable populations.

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 prior data suggests that these advance care planning interventions are safe for older homeless adults?

Research shows that both group and one-on-one advance care planning (ACP) sessions are generally well-received by participants. Previous studies have found these ACP sessions effective in increasing patient satisfaction and involvement without causing significant problems. The sessions often include easy-to-read materials and guided discussions to help participants understand their healthcare options.

Reports from past trials do not indicate any serious negative effects from these sessions. Instead, participants usually find them helpful for making informed decisions about their future healthcare. Since this trial does not test a new drug or medical procedure, the risks are minimal. Participants can expect a safe environment focused on planning their healthcare wishes. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about this trial because it focuses on advance care planning (ACP) for older homeless adults, a group often overlooked in healthcare planning. Unlike traditional ACP methods that might not consider the unique challenges faced by this population, this trial uses tailored, facilitated sessions, both one-on-one and in groups, to engage participants. The use of a movie version of the PREPARE program, along with new content specific to permanent supportive housing (PSH), makes the process more relatable and accessible. By incorporating easy-to-read advance directives and personalized video content, this approach aims to empower individuals to make informed decisions about their healthcare priorities.

What evidence suggests that this trial's advance care planning interventions could be effective for older homeless adults?

Research has shown that planning for future medical care, known as advance care planning (ACP), helps patients with serious health issues feel more involved and satisfied with their care. This applies to older adults who have experienced homelessness as well. In this trial, participants will attend either a facilitated group ACP session or a facilitated one-on-one ACP visit. Studies indicate that these ACP sessions, whether in groups or one-on-one, help people prepare for future medical decisions and increase participation in making choices about end-of-life care. This can lead to healthcare that is more personalized and respects individual wishes. Overall, participating in these sessions can significantly ensure that personal preferences are followed. ^{1 2 3 6 7}

Who Is on the Research Team?

Rebecca Sudore, MD

Principal Investigator

University of California, San Francisco

Margot Kushel, MD

Principal Investigator

University of California, San Francisco

Are You a Good Fit for This Trial?

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 for a Trial Participant

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

What Are the Treatments Tested in This Trial?

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.

How Is the Trial Designed?

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+

Published Research Related to This Trial

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]

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]

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]

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]

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]

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]

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]

Citations

1. clinicaltrials.gov clinicaltrials.gov/study/NCT06239896

Advance Care Planning With Formerly Homeless Older ... The goal of this randomized control trial (RCT) is to test the effectiveness of adapted evidence-based advance care planning (ACP) interventions for formerly ...

2. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC6105505/

Advance Care Planning among Older Homeless ... Abstract. Older homeless-experienced adults have low engagement in advance care planning (ACP) despite high morbidity and mortality.

3. withpower.com withpower.com/trial/phase-advance-care-planning-2-2024-1b495

Advance Care Planning 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 ...

4. nhchc.org nhchc.org/wp-content/uploads/2019/08/in-focus-advance-care-planning-final-for-posting-1.pdf

Advance Care Planning for Individuals Experiencing ... It gives an overview of morbidity and mortality of the homeless population, their concerns about death, advance care preferences, and implications for practice.

5. agsjournals.onlinelibrary.wiley.com agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18314

Using behavioral theory to adapt advance care planning for ... We identified behavioral determinants related to ACP for formerly chronically homeless older adults in PSH.

6. pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov/29741765/

Advance Care Planning for Older Homeless-Experienced Adults Advance Care Planning for Older Homeless-Experienced Adults: Results from the Health Outcomes of People Experiencing Homelessness in Older Middle Age Study.

7. sciencedirect.com sciencedirect.com/science/article/pii/S088539242401042X

Essential Advance Care Planning Intervention Features in ... This article describes a qualitative study to obtain participant preferences for advance care planning interventions for older adults with low socioeconomic ...