Co-designing an Advance Care Planning Conversation Toolkit for Older People with Frailty Receiving Hospital at Home: A Participatory Intervention Development Study

Abstract Purpose Advance care planning (ACP) is particularly relevant for older people receiving Hospital at Home (H@H) care, many of whom live with frailty. However, clinicians may feel uncertain about how to initiate ACP conversations compassionately and practically in home-based acute care. We aimed to co-design an ACP conversation toolkit for H@H. Methods We used a participatory co-design approach to refine a draft ACP toolkit with clinicians, patients, family members and public contributors. The co-design phase included one clinician workshop (n = 19), two patient/public workshops (n = 6) and one individual lived-experience interview (n = 1). Sessions explored toolkit language, sequencing, explanations of treatment and cardiopulmonary resuscitation, safety-netting and supporting materials. Data were captured through facilitated discussion, structured notes, prioritisation tasks and iterative review of draft components. Analysis focused on clarity, emotional impact, relational safety, acceptability and usability. Results Co-design identified six priorities: clear explanation of ACP, attention to timing and readiness, cultural and linguistic sensitivity, values-based discussion before treatment-specific decisions, plain and non-coercive language, and reassurance that preferences can be reviewed. The toolkit was revised from a scripted format into a flexible, multi-component conversational scaffold comprising a patient conversation guide, family support tool, quick-reference card and clinician reflection diary, aligned with a Three-Talk shared decision-making structure. Preliminary feedback suggested acceptability, with 62/72 (86.1%) staff item responses and 53/56 (94.6%) patient/family item responses rated agree or strongly agree. Conclusion Co-design reshaped the toolkit into a flexible, values-led conversational scaffold suited to the relational, ethical and practical realities of ACP in H@H.