A broader understanding of care managers' attitudes of advance care planning: A concurrent nested design.

Aims And Objectives: To examine barriers of advance care planning (ACP) experienced by care managers (CMs) through a mixed methods approach. A concurrent nested design was used to acquire a deeper understanding of ACP and to identify nuances between quantitative and qualitative data.

Background: Past quantitative studies on providers have identified barriers related to time, culture, knowledge, responsibility and availability of legal documents. These barriers, and accompanying attitudes and feelings, have been taken at face value without rich qualitative data to identify under what conditions and to what extent a barrier impacts care.

Design: A two-part multisite, mixed methods study was conducted using surveys and focus groups.

Methods: Surveys were completed by 458 CMs at 10 Area Agencies on Aging and 62 participated in one of eight focus groups. Data were analysed using a concurrent nested design with individual data analysis and a merged data approach.

Results: There were three main distinctions between the quantitative and qualitative data. First, while CMs reported on the survey that ACP was not too time consuming, focus group data revealed that time was an issue especially related to competing priorities. Second on the survey 60% of the CMS reported they had enough knowledge, but qualitative data revealed about more nuances. Last, the reported comfort levels in the quantitative data were less overt in the qualitative date where additional feelings and attitudes were revealed, for example, frustration with families, preferences for more physician involvement.

Conclusions: Care managers reported their attitudes about ACP, clarified through a rigorous mixed methods analysis. Care managers can successfully lead ACP discussions, but require further education, resources and team-based guidance.

Relevance To Clinical Practice: Advance care planning is essential for reducing emotional, social and financial burdens associated with healthcare decision-making, and CMs can positively impact ACP discussions when appropriately supported by the clinical community. The many nuances in the ACP process that we found illustrate the need for ongoing discussions, education and research on this important topic.