Table 3 KHPs views on the role, setting, and aspects of the nurse-led ACP intervention
What do ACP nurses / practitioners do? | • Working with GPs for patient selection according to eligibility criteria • Regular home visits (needs-based duration) • Identify risk of functional decline • Holistic assessment • Active listening • Person-centred care • Co-developing and regular reviewing of advance care plan with patient (and family carer / advocate) • Work with pharmacist for medication review • Liaise with geriatricians, physios, OTs and other health professionals • Liaising with, and signposting to, the voluntary and community sector • Have a level of seniority |
Where are they located? | • Based in primary care • Within Trusts (NI) and Community Health Organizations (ROI) • Allied to Older People Care, and Geriatricians |
What structures and support are required for this service? | • Inclusive eligibility criteria with right to self-determination • ACP training incorporated into UG student curriculum • Ongoing ACP training available for qualified nurses • Supervision for ACP nurses • Shared electronic records • Standardized procedures • Competency framework • Structured approach • Integration in to existing structures in both jurisdictions for this patient group (avoiding duplication) • Implementation in line with current health system reforms in both jurisdictions |