Advanced Care PlanningNCT06238063
Implementing a Nurse-led Advance Care Planning (ACP) Intervention in Residential Care Homes
A study testing Nurse-led Advance Care Planning (ACP) Intervention in people with Advanced Care Planning, run by The University of Hong Kong at 1 site in Hong Kong.
Trial summary
The goal of this cluster randomized controlled trial is to examine the effectiveness of a nurse-led advance care planning (ACP) intervention on improving ACP discussion uptake in residential care homes (RCHs). Read more about this study
- Who is it for?
- Ages 65 years and olderHealthy volunteers can take part
- Conditions the study is for
- Advanced Care Planning
- What is being tested?
- Nurse-led Advance Care Planning (ACP) Intervention
- Type of treatment
- Lifestyle or therapy programme
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 164 participants
- Where
- 1 siteHong Kong
- Study dates
- 1 Jul 2022to 31 Dec 2025
- Phase
- Interventional
- Are there results?
- Not yet: the study is under way
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 65 years and older
- All sexes
- Healthy volunteers accepted
- Older adult
Who may be able to join
- Eligible participants have to be age 65 or older and be able to communicate in Cantonese or Mandarin.
- Participants will also be invited to identify family members involved in making decisions about their care to participate in the intervention. For residents who have moderate or severe cognitive impairment (as determined by a score of less than 19 in the Hong Kong version of the Montreal Cognitive Assessment), the participation of family members is mandatory.
Who cannot join
- They have a moderate or severe significant cognitive impairment but do not have family members, or
- They have prior ACP experience (e.g., AD completed).
Trial locations and contacts
1 site in 1 country. Contact the study team or a site near you to ask about taking part.
Hong Kong1 site, 1 recruiting
- Recruiting
The University of Hong Kong
Hong Kong
Chia-Chin Lin, PhD, 39176633, cclin@hku.hk
About this study
Official title: Implementing a Nurse-led Advance Care Planning (ACP) Intervention to Improve ACP Uptake in Residential Care Homes: An Implementation Science and Mixed Methods Pragmatic Cluster Randomized Controlled Trial
The goal of this cluster randomized controlled trial is to examine the effectiveness of a nurse-led advance care planning (ACP) intervention on improving ACP discussion uptake in residential care homes (RCHs). The main question it aims to answer is: The effectiveness of nurse-led advance care planning (ACP) interventions implemented on eligible residents in residential care homes on improving ACP discussion uptake in this population.
Compared to participants in the control group who will only receive usual care with no ACP intervention, residents and their family members in the intervention group will be invited to attend the ICP meeting with ACP discussion. The ACP discussion will be guided by the established protocol, which was developed by the expert panel and delivered by trained nurses.
Read the detailed description
Targeted issue: The lack of ACP discussion and poor dyadic congruence pose challenges to the provision of good EOL care in Hong Kong RCHs.
Population: RCHs in Hong Kong with nurse-to-resident ratios ≥1:3 will be targeted to ensure adequate staffing to carry out ACP. Eligible participants have to be age 65 or older and be able to communicate in Cantonese or Mandarin. Participants will also be invited to identify family members involved in making decisions about their care to participate in the intervention.
Intervention: a nurse-led advance care planning (ACP) intervention
Main study aim: To implement a nurse-led ACP intervention for improving ACP uptake in RCH residents in Hong Kong to bridge the evidence-practice gap.
Study method: This implementation science study will use a mixed methods approach, including a pair-matched cluster-RCT and qualitative interviews, and relevant outcomes will be followed for up to 2 years. RCHs will be randomized into two groups: a nurse-led ACP intervention group and a control group with usual care only.The ACP documentation (i.e., new documentation related to ACP and EOL care) in medical records of all RCH residents in the intervention and control groups will be audited by the research team at baseline (T0), post-intervention (T1; after the ACP intervention), 1-year follow-up (T2; 1 year after the launch of the ACP intervention at the RCH), and 2-year follow-up (T3; 2 years after the launch of the ACP intervention at the RCH).
- Conditions
- Advanced Care Planning
- Being tested
- Nurse-led Advance Care Planning (ACP) Intervention
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Nurse-led Advance Care Planning (ACP) InterventionBehavioural
An ACP discussion between the participating resident, family members, and the trained nurse will be incorporated into the annual review. The proposed ACP intervention will be divided into three parts (three weekly sessions, 1.5 hours each): 1) preparatory, 2) discussion, and 3) follow-up sessions.
| Study group | Role | What they receive |
|---|---|---|
| Intervention | Experimental | The ACP intervention, which was developed by the expert panel, will be delivered by trained nurses in each RCH during a mandatory annual individual care planning (ICP) meeting. Eligible residents and their family members will be invited to attend the ICP meeting with ACP discussion. Receives: Behavioral: Nurse-led Advance Care Planning (ACP) Intervention |
| Control | No intervention | Participants in the control arm will receive usual care with no ACP intervention. |
What is being measured
The primary outcome is the main question the study is designed to answer.
Change from Baseline in Chart review at post-intervention
The medical records of all RCH residents will be audited at baseline (T0), post-intervention (T1; after the ACP intervention), 1-year follow-up (T2; 1 year after the launch of the ACP intervention at the RCH), and 2-year follow-up (T3; 2 years after the launch of the ACP intervention at the RCH). The following information will be extracted: ACP documentation (primary outcome; i.e., new documentation related to ACP and EOL care); designated surrogate decision-maker; AD completion; and healthcare utilization (i.e., number of inpatient hospitalizations, emergency department visits, intensive care unit admissions and length of stay, mechanical intubation rates and in-hospital cardiopulmonary resuscitation rates during the 6 months before death, place of death). The information specific to ACP intervention will only be extracted in residents who participated in ACP intervention: concordance on EOL preferences ; and concordance between preferred and actual outcomes of EOL care.
Measured: baseline and immediately after the intervention
Change from Baseline in Chart review at 1-year follow-up time point.
The medical records of all RCH residents will be audited at baseline (T0), post-intervention (T1; after the ACP intervention), 1-year follow-up (T2; 1 year after the launch of the ACP intervention at the RCH), and 2-year follow-up (T3; 2 years after the launch of the ACP intervention at the RCH). The following information will be extracted: ACP documentation (primary outcome; i.e., new documentation related to ACP and EOL care); designated surrogate decision-maker; AD completion; and healthcare utilization (i.e., number of inpatient hospitalizations, emergency department visits, intensive care unit admissions and length of stay, mechanical intubation rates and in-hospital cardiopulmonary resuscitation rates during the 6 months before death, place of death). The information specific to ACP intervention will only be extracted in residents who participated in ACP intervention: concordance on EOL preferences ; and concordance between preferred and actual outcomes of EOL care.
Measured: 1-year follow-up (i.e., 1 year after the launch of the ACP intervention)
Change from Baseline in Chart review at 2-year follow-up time point.
The medical records of all RCH residents will be audited at baseline (T0), post-intervention (T1; after the ACP intervention), 1-year follow-up (T2; 1 year after the launch of the ACP intervention at the RCH), and 2-year follow-up (T3; 2 years after the launch of the ACP intervention at the RCH). The following information will be extracted: ACP documentation (primary outcome; i.e., new documentation related to ACP and EOL care); designated surrogate decision-maker; AD completion; and healthcare utilization (i.e., number of inpatient hospitalizations, emergency department visits, intensive care unit admissions and length of stay, mechanical intubation rates and in-hospital cardiopulmonary resuscitation rates during the 6 months before death, place of death). The information specific to ACP intervention will only be extracted in residents who participated in ACP intervention: concordance on EOL preferences ; and concordance between preferred and actual outcomes of EOL care.
Measured: 2-year follow-up (i.e., 2 years after the launch of the ACP intervention at the RCH).
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted2 Feb 2024
- Study start1 Jul 2022
- Primary completion31 Oct 2025 (estimated)
- Study completion31 Dec 2025 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (1)Papers the sponsor has linked to this study.
- Other trials for Advanced Care PlanningStudies of the same condition, open and under way.
- More trials run by The University of Hong KongThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Supportive care
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Enrolment
- 164 participants (estimated)
Sponsor and investigators
- Lead sponsor
- The University of Hong Kong
- Sponsor type
- University, hospital or other
- Responsible party
- Sponsor
- Investigators
- Chia-Chin Lin, PhD, Principal investigator, The University of Hong Kong
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT06238063
- Sponsor's protocol ID
- UW 22-021
- Status last verified
- Jun 2025
- First submitted
- 23 Mar 2023
- Last updated
- 11 Jul 2025
- Results posted
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Publications
Wang T, Cheung DST, Chu C, Chen J, Lin CC. Evaluation of a train-the-trainer implementation strategy on providers' competency, opportunity and motivation for advance care planning in residential care homes: a mixed-methods study. BMC Geriatr. 2026 Jan 3;26(1):155. doi: 10.1186/s12877-025-06898-2.
PubMed 41484702
Study at a glance
From the registry record, last updated by the sponsor on 11 Jul 2025. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Implementing a Nurse-led Advance Care Planning (ACP) Intervention to Improve ACP Uptake in Residential Care Homes: An Implementation Science and Mixed Methods Pragmatic Cluster Randomized Controlled Trial
- ClinicalTrials.gov ID
- NCT06238063
- Acronym / sponsor ID
- UW 22-021
- Conditions
- Advanced Care Planning
- Study type
- Interventional
- Recruitment status
- Recruiting
- Enrolment
- 164 participants (estimated)
- Lead sponsor
- The University of Hong KongUniversity, hospital or other
- Study start
- 1 Jul 2022 (actual)
- Primary completion
- 31 Oct 2025 (estimated)
- Study completion
- 31 Dec 2025 (estimated)
- First posted
- 2 Feb 2024 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
The goal of this cluster randomized controlled trial is to examine the effectiveness of a nurse-led advance care planning (ACP) intervention on improving ACP discussion uptake in residential care homes (RCHs). The main question it aims to answer is: The effectiveness of nurse-led advance care planning (ACP) interventions implemented on eligible residents in residential care homes on improving ACP discussion uptake in this population.
Compared to participants in the control group who will only receive usual care with no ACP intervention, residents and their family members in the intervention group will be invited to attend the ICP meeting with ACP discussion. The ACP discussion will be guided by the established protocol, which was developed by the expert panel and delivered by trained nurses.
Detailed description
Targeted issue: The lack of ACP discussion and poor dyadic congruence pose challenges to the provision of good EOL care in Hong Kong RCHs.
Population: RCHs in Hong Kong with nurse-to-resident ratios ≥1:3 will be targeted to ensure adequate staffing to carry out ACP. Eligible participants have to be age 65 or older and be able to communicate in Cantonese or Mandarin. Participants will also be invited to identify family members involved in making decisions about their care to participate in the intervention.
Intervention: a nurse-led advance care planning (ACP) intervention
Main study aim: To implement a nurse-led ACP intervention for improving ACP uptake in RCH residents in Hong Kong to bridge the evidence-practice gap.
Study method: This implementation science study will use a mixed methods approach, including a pair-matched cluster-RCT and qualitative interviews, and relevant outcomes will be followed for up to 2 years. RCHs will be randomized into two groups: a nurse-led ACP intervention group and a control group with usual care only.The ACP documentation (i.e., new documentation related to ACP and EOL care) in medical records of all RCH residents in the intervention and control groups will be audited by the research team at baseline (T0), post-intervention (T1; after the ACP intervention), 1-year follow-up (T2; 1 year after the launch of the ACP intervention at the RCH), and 2-year follow-up (T3; 2 years after the launch of the ACP intervention at the RCH).
Study design
- Primary purpose
- Supportive care
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Number of arms
- 2
| Arm | Type | Receives |
|---|---|---|
| Intervention | Experimental | Behavioral: Nurse-led Advance Care Planning (ACP) InterventionThe ACP intervention, which was developed by the expert panel, will be delivered by trained nurses in each RCH during a mandatory annual individual care planning (ICP) meeting. Eligible residents and their family members will be invited to attend the ICP meeting with ACP discussion. |
| Control | No intervention | –Participants in the control arm will receive usual care with no ACP intervention. |
Who may qualify
- Ages
- 65 years and older
- Sex
- All
- Healthy volunteers
- Accepted
- Age groups
- Older adult
Key inclusion criteria (2 listed)
- Eligible participants have to be age 65 or older and be able to communicate in Cantonese or Mandarin.
- Participants will also be invited to identify family members involved in making decisions about their care to participate in the intervention. For residents who have moderate or severe cognitive impairment (as determined by a score of less than 19 in the Hong Kong version of the Montreal Cognitive Assessment), the participation of family members is mandatory.
Key exclusion criteria (2 listed)
- They have a moderate or severe significant cognitive impairment but do not have family members, or
- They have prior ACP experience (e.g., AD completed).
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Nurse-led Advance Care Planning (ACP) InterventionAn ACP discussion between the participating resident, family members, and the trained nurse will be incorporated into the annual review. The proposed ACP intervention will be divided into three parts (three weekly sessions, 1.5 hours each): 1) preparatory, 2) discussion, and 3) follow-up sessions. | Behavioural | Intervention |
Primary outcome
Change from Baseline in Chart review at post-intervention
Time frame: baseline and immediately after the intervention
The medical records of all RCH residents will be audited at baseline (T0), post-intervention (T1; after the ACP intervention), 1-year follow-up (T2; 1 year after the launch of the ACP intervention at the RCH), and 2-year follow-up (T3; 2 years after the launch of the ACP intervention at the RCH). The following information will be extracted: ACP documentation (primary outcome; i.e., new documentation related to ACP and EOL care); designated surrogate decision-maker; AD completion; and healthcare utilization (i.e., number of inpatient hospitalizations, emergency department visits, intensive care unit admissions and length of stay, mechanical intubation rates and in-hospital cardiopulmonary resuscitation rates during the 6 months before death, place of death). The information specific to ACP intervention will only be extracted in residents who participated in ACP intervention: concordance on EOL preferences ; and concordance between preferred and actual outcomes of EOL care.
Change from Baseline in Chart review at 1-year follow-up time point.
Time frame: 1-year follow-up (i.e., 1 year after the launch of the ACP intervention)
The medical records of all RCH residents will be audited at baseline (T0), post-intervention (T1; after the ACP intervention), 1-year follow-up (T2; 1 year after the launch of the ACP intervention at the RCH), and 2-year follow-up (T3; 2 years after the launch of the ACP intervention at the RCH). The following information will be extracted: ACP documentation (primary outcome; i.e., new documentation related to ACP and EOL care); designated surrogate decision-maker; AD completion; and healthcare utilization (i.e., number of inpatient hospitalizations, emergency department visits, intensive care unit admissions and length of stay, mechanical intubation rates and in-hospital cardiopulmonary resuscitation rates during the 6 months before death, place of death). The information specific to ACP intervention will only be extracted in residents who participated in ACP intervention: concordance on EOL preferences ; and concordance between preferred and actual outcomes of EOL care.
Change from Baseline in Chart review at 2-year follow-up time point.
Time frame: 2-year follow-up (i.e., 2 years after the launch of the ACP intervention at the RCH).
The medical records of all RCH residents will be audited at baseline (T0), post-intervention (T1; after the ACP intervention), 1-year follow-up (T2; 1 year after the launch of the ACP intervention at the RCH), and 2-year follow-up (T3; 2 years after the launch of the ACP intervention at the RCH). The following information will be extracted: ACP documentation (primary outcome; i.e., new documentation related to ACP and EOL care); designated surrogate decision-maker; AD completion; and healthcare utilization (i.e., number of inpatient hospitalizations, emergency department visits, intensive care unit admissions and length of stay, mechanical intubation rates and in-hospital cardiopulmonary resuscitation rates during the 6 months before death, place of death). The information specific to ACP intervention will only be extracted in residents who participated in ACP intervention: concordance on EOL preferences ; and concordance between preferred and actual outcomes of EOL care.
Results and safety
This study is still under way. Results are not available in the source record yet.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 11 Jul 2025.
- Derived from this study: PubMed 41484702Wang T, Cheung DST, Chu C, Chen J, Lin CC. Evaluation of a train-the-trainer implementation strategy on providers' competency, opportunity and motivation for advance care planning in residential care homes: a mixed-methods study. BMC Geriatr. 2026 Jan 3;26(1):155. doi: 10.1186/s12877-025-06898-2.
- Individual participant dataSharing planned: No
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part.
Chia-Chin Lin, PhD principal investigator
The University of Hong Kong
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Nurse-led Advance Care Planning (ACP) Intervention in people with Advanced Care Planning, run by The University of Hong Kong at 1 site in Hong Kong.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 2 inclusion and 2 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: looking for participants now, as of the sponsor's last update on 11 Jul 2025. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in Hong Kong. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
This study is still under way. Results are not available in the source record yet.
How can a doctor refer a patient or contact the research team?
Contact Chia-Chin Lin, PhD (39176633, cclin@hku.hk), or a site near the patient. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Change from Baseline in Chart review at post-intervention (time frame: baseline and immediately after the intervention). The study lists 3 primary outcomes in all. It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT06238063, which also lists 1 linked publication.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 11 Jul 2025.