A systematic process to enhance selection of a prepared medical decision maker.

Abstract

5 Background: Selecting a prepared medical decision maker (MDM) is an integral component of advance care planning (ACP), an interdisciplinary process supported by prognostic awareness. ASCO’s Quality Initiative recommends providers discuss ACP or advance directives (AD) with all new patients with invasive malignancy (NP) by the third office visit (OV). In this quality improvement project, our goal was to increase documented social work (SW), counseling, and education regarding selection of a prepared MDM to 70% and to increase scanned MPOA in EHR 2x by 3R OV. Methods: All SW received institutional training regarding important elements to include when providing counseling and education regarding selection of a prepared MDM. We collected data from EHR of all NP of five gynecologic oncologist champions, including responses to patient needs survey (PNS), AD questions at first OV and ACP physician/Advanced Practice Provider (MD/APP), and SW ACP notes derived from templates with structured elements. Data were collected during baseline and three intervention cycles (C). C1: coaching RN to ask PNS AD questions from a “culture of yes”, C2: NP viewing brief video about importance of MPOA; C3: providing cards with simple definitions of AD to use with NP. Results are presented for C1-3 versus baseline. Results: Total NP=351 (baseline 133, C1-3 218). Intervention group (IG) patients requested more assistance with AD (15 vs. 5%, p=.005) and wanted more information (16 vs. 8%, p=.02) than baseline. Documented social work ACP notes by the third OV were less frequent in the IG (30 vs. 48%, p=.001); there were fewer documented SW ACP notes in those without scanned MPOA (72 vs. 58% without note, p=.01), and no increase in scanned MPOA (13 vs. 11%, p=.516). Physician documentation of MPOA discussion increased (38 vs. 8%, P.000), but discussion of treatment goals did not (84 vs. 68%, p=.112). Conclusions: Interventions resulted in increased MD/APP discussions of importance of MPOA and NP requests for discussion, but fewer SW ACP discussions. There was no increase in scanned MPOA. Current processes reach only a minority of NP and do not effectively engage NP in selecting a prepared MDM. More proactive approaches systematically incorporating ACP discussions into care in an iterative manner are needed.