{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,9]],"date-time":"2026-03-09T06:00:18Z","timestamp":1773036018153,"version":"3.50.1"},"reference-count":39,"publisher":"Wiley","issue":"3","license":[{"start":{"date-parts":[[2026,1,30]],"date-time":"2026-01-30T00:00:00Z","timestamp":1769731200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,1,30]],"date-time":"2026-01-30T00:00:00Z","timestamp":1769731200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/100000049","name":"National Institute on Aging","doi-asserted-by":"publisher","award":["R33AG057463"],"award-info":[{"award-number":["R33AG057463"]}],"id":[{"id":"10.13039\/100000049","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["agsjournals.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["J American Geriatrics Society"],"published-print":{"date-parts":[[2026,3]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Embedded pragmatic clinical trials are an ideal way to develop and evaluate evidence\u2010based interventions in the nursing home (NH) environment to facilitate streamlining implementation after study completion. However, there is minimal information available about the necessary and sufficient conditions of \u201cdifference makers\u201d for robust implementation of pragmatic interventions in the NH setting.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>The \u201cAligning Patient Preferences\u2014a Role Offering Alzheimer's patients, Caregivers, and Healthcare Providers Education and Support\u201d (APPROACHES) embedded pragmatic trial is designed to test and evaluate a staff\u2010led advance care planning (ACP) intervention for residents with dementia in 128 NHs (64 intervention, 64 control). Coincidence Analysis, a case\u2010based approach to data analysis that draws upon Boolean algebra and set theory, was applied to identify key difference\u2010makers for robust implementation. This analysis focused on the 44 intervention NHs that implemented at least one of two implementation processes: site visits and\/or monthly calls.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Eighteen of 44 (41%) sites in the analysis robustly implemented the APPROACHES intervention as reflected by &gt;\u200975% of residents having a documented ACP conversation. The Coincidence Analysis revealed two pathways directly linked with robust pragmatic implementation: (1) no executive director turnover during the observation period combined with site participation in monthly calls with peers; and (2) higher rates of baseline hospitalization (3.96\u20137.0 per 1000 resident\u2010days alive) combined with a low number of certified beds. In contrast, leadership instability as reflected by administrator turnover, high number of certified beds, and a lack of participation in monthly calls with peers was associated with poorer performance.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>Findings from this study suggest that leadership stability and engagement with peers were essential drivers of robust implementation of the APPROACHES ACP Specialist intervention. Coincidence Analysis is a useful tool for understanding how implementation conditions are associated with robust implementation in embedded pragmatic clinical trials.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/jgs.70289","type":"journal-article","created":{"date-parts":[[2026,1,30]],"date-time":"2026-01-30T08:49:59Z","timestamp":1769762999000},"page":"712-721","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Difference\u2010Makers for Robust Implementation of a Nursing Home Advance Care Planning Embedded Pragmatic Clinical Trial"],"prefix":"10.1111","volume":"74","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1514-8430","authenticated-orcid":false,"given":"Susan E.","family":"Hickman","sequence":"first","affiliation":[{"name":"School of Nursing Indiana University  Indiana USA"},{"name":"School of Medicine Indiana University  Indiana USA"},{"name":"IU Center for Aging Research Regenstrief Institute Inc.  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