Background Implementing ACP in nursing homes is often essentially done by educating selected n/h staff as ACP facilitators. Recent German legislation covers ACP offered to nursing home residents, and offers an alternative strategy for implementation, i.e. cooperation of participating n/hs with a regional (central) partner that employs a team of facilitators. Which of these two strategies should be preferred?

Methods 1. Follow-up of facilitator training effectivity in Germany in 2015–2017, 2. review of the literature, 3. theoretical analysis of the competing rationales.

Results Of some 270 facilitator trainees attending our ACP courses, only few report ongoing practice as an ACP facilitator. A number of important publications describe facilitators and barriers, or essential elements, of successful ACP implementation, but few if any compare regional versus institutional implementation strategies of ACP yet. Similarly, while regional ACP coordination is described as an important precondition for sustainable ACP implementation, it requires significant resources on top of institutional implementation. A comparative analysis yields a number of strong reasons why regional may well beat institutional implementation strategies, referring to staff aptitude, team building, regional coordination, economic efficiency, and both sustainability and expandibility. Arguments that have been raised against qualifying external staff can be shown not to consider sufficiently the potential of creating regional (central) facilitator teams.

Conclusion Regional implementation of ACP, characterised by regional (central) facilitator teams cooperating with nursing homes and other institutions, has yet rarely been described, but poses a substantial potential when compared to conventional institutional implementation strategies that deserves scientific evaluation.