Table 1 Implementing stakeholders thematic framework

General practitioners and practice managers

• Existing ACP efforts—beware of duplication: Medical Care Planning

S

OS

‘We are a practice that does a lot of Medical Care Planning. And it's structured in a way that you are remunerated for the work that you do.’ [ ] ‘We wouldn't be trying to organize anything extra.’

L3PM

• Funding, staffing, and time are barriers

OS

‘I think it's the challenge of scaling it up in terms of funding and personnel.’

‘The challenge would be the time. Time was the biggest challenge.’

‘Unless there's greater funding going into social care, I really feel it's going to be very difficult to care for patients in their homes.’

L3GP

F6GP

L3GP

• Participation was enjoyable as was made easy by study team

PI

‘So, from our point of view, from your side you’ve made it very easy. It hasn’t been a difficult one; it has been a good experience for us.’

L3GP

• Trained ACP Nurses doing home visits facilitates ACP

S

IC/CIN

‘The home visit from the nurse was very good because as GPs, you know, we’re covering a big rural area.’

‘As GPs we have limited time because we're also running acute surgeries and all the rest of what we do.’

F6GP

L3GP

• Medication review requires access to patient medical history to be effective

S

IC

‘I suppose when the drugs were reviewed; it was a pharmacist outside that was used, so they didn't really have the full clinical information about the patient. I suppose we have our own practice pharmacist now.’

‘The medication review was good for sure.’

L3GP

F6GP

• Multidisciplinary teams are central to intervention

IC/CIN

‘I suppose we're mainly talking about the multidisciplinary team in order to make it happen.’

L3GP

• Fragmentation of Services is a barrier

OS

‘Even though we all provide primary care, I'm isolated from the public health nurses and I’m also isolated from the physicians; OT’s. So that is a bit of an issue.’

EGP

Pharmacist

• Medication review should be done by pharmacist

S

IC

‘I think we’ve realized now that with really good care of the older patient, that each of the health care professionals has their own individual role. And where the nurses did a fantastic job, elucidating somebody’s drug history is not their speciality. That would be the role of the pharmacist.’

PHST

• ACP is essential for older adults

IC

‘I think with the volume of patients and the workload that's already heaped upon GPs and the way that there's sort of a filter for information coming from secondary care, from specialist services, that it's very difficult to pay the attention to detail that's needed to provide a really good quality health care service for older patients. So, it's absolutely essential, I think, for the care of older people.’

PHST

• Lack of access to patient data was a barrier

PI

‘The one thing that did impede the flow was the anonymizing of the information from the southern participants. So, each document that they sent me was password protected and redacted. I think it was a bit of an overkill, because the NI RNs just emailed me with the patient's confidential details omitted which worked completely fine. I couldn't identify the patient if I tried but, you know, the pertinent information is still there.’

PHST

• Lack of access to past medical history was a barrier

PI

‘But the real problem that I faced was the lack of information and the information in situ. [ ] And I think if the study was to be redesigned, then the gold standard would be that the pharmacist would do their own medicines reconciliation or medicines review with the patients themselves and have access to all the information that I would have in my general routine in practice.’

PHST

• Sustained constructive collaboration from the study team

PI

‘A huge thanks to the team, they were entirely inclusive and really open to all the sessions at every point along the way. It's been an absolute delight to work with them and it's been a really positive experience overall for me.’

PHST

• Existing ACP efforts–beware of duplication: comprehensive geriatric assessment

S

OS

‘We would call it Comprehensive Geriatric Assessment and it would be in our team; it's consultant led and consultant geriatrician and he’d lead our team and undertake it to reach patients, and but then we have our full MDT.’

PHST

• Multidisciplinary teams are central to ACP

S

IC/CIN

‘So, we understand the need for OT, physio and social work, and speech and language therapy, nursing staff. You know, everybody has their own clear and visible roles and it's all very important to the elderly.’

PHST

Nurses

• Appropriateness of PRISMA-7 for patient selection

PI

‘The patients fill out the Prisma-7 questionnaire, and that is a self-reported questionnaire of their frailty. And I didn't think that was terribly accurate.’

‘A lot of the patients that we went out to see didn't have that many needs identified. And on numerous occasions we came out and thought how did they get in through the selection process?’

RN3

RN2

• Training was beneficial

PI

‘I thought the training was very good. There were three days training and I enjoyed it a lot. I really did think it was it was comprehensive and delivered very, very well.

‘It was a bit more detailed than what we eventually ended up doing. But yes, I did feel it was great to have the talk from the pharmacist. You know, everybody had their part to do of their speciality. So, you got the benefit of all that.’

RN1

RN3

• ACP home visits are key for best outcomes

S

IC

‘Certainly, for some patients, I don't think it could have been done anywhere else.’

‘Yes, because you can get a lot of insight from them in terms of, you know, other hazards around; does the place look cared for? Do they look cared for? How they are mobilizing in their own environment and things like that.’

‘I thought it was very appropriate, because there you got an insight into their housing conditions, into their social conditions.’

RN3

RN2

RN5

• Procedural sequence facilitated the research nurses’ role

PI

‘There was a lot that we did like yeah! The training was very good. And then the follow through, we went out with [name] the pharmacist to see what her role was and the fact that [the patients] had already consented by the time we got out. The procedure of each step was well thought out.’

RN2

• Patients appreciated the intervention

IS

‘And from, you know, speaking to the patients. They really appreciated it. Definitely. It could work really well for the ones who did need it.’

RN1

• GP ideal setting but lack of time is barrier

S

IS

‘Well, GPs and practice nurses definitely would not have time for it. But the Federations now have practice-based pharmacists and social workers. So, there are other people, you know, in GP practices who might be able to help.’

RN1

• Experienced nurse with specific skillset required: older adults, person-centred, chronic illness, health and social care system, community, and voluntary groups

IC/CIN

‘I think you possibly need the development of a GP primary care outreach nurse.’

‘Somebody with experience of chronic illness and, because it is based in the community, an understanding of community services would be useful.’

‘Knowing how to approach the older person, how to build that trusting relationship.’

‘Having a good insight into community support that's available and what's available within the surgery and having good communication skills with the relevant GP and having a good system to fall back on, to get actions put into place.’

RN5

RN4

RN5

RN2

• Lack of communication and protocols for data collection and recording was a barrier

PI

‘Just better communication from the study team throughout the study and better communication also between the nurses in the South and the nurses in the north.’

‘I didn't feel at sea in any way and understood what had to be achieved in terms of the actual intervention. But I think I come back to my previous issue, which was knowing what data I should be collecting or capturing and whether I should be doing it in another way or different way.’

RN1

RN4

• Multidisciplinary teams are central to ACP

S

IC/CIN

‘But I think that it needs to be taken on by somebody other. It's not a GP or practice nurses’ job to provision the time for it but all these new people now with the multi-disciplinary teams. Then I think, you know, you have some kind of mechanism there by which you could make it work.’

RN1