Innovative pilot to reimburse nurse and social work-led advance care planning.

Abstract

3 Background: Research has shown that advance care planning (ACP) leads to better patient care and outcomes. The Oregon Health Leadership Council (OHLC) identified ACP as an opportunity to improve care and offset costs. In 2014, the OHLC commissioned a workgroup to pilot a payment model to promote broader adoption of ACP. A community oncology provider and 4 health plans implemented the pilot for nurses (RNs) and licensed clinical social workers (LCSWs) to conduct ACP in an effort to elicit and honor patient preferences at end of life (EOL). Methods: Five RNs and 2 LCSWs underwent specific ACP training (by academic EOL educator or VitalTalk). They conducted one or more substantive ACP conversations (minimum 20 minutes) with 149 patients (89 female, 60 male; median age 64; range 24-92) between 12/5/14 and 5/9/16. Most patients had recurrent and/or metastatic cancer. Charts were reviewed in April 2017 for goals of care (GOC) discussion, ACP documents, preferences for EOL care, hospice enrollment, date of death, and death location. Results: Among all 149 patients, GOC discussion was documented for 126 (85%). Advance directives were in the chart for 34 (23%) and POLST for 53 (36%) patients. Among the 69 patients who died, 80% were on hospice (median days = 14; 15% on hospice < 3 days); 87% preferred comfort care at time of death. Three patients (4%) requested life-prolonging treatment until death. Conclusions: This pilot demonstrated that RNs and LCSWs can provide substantive ACP within robust team-based care. Hospice enrollment, POLST completion, and EOL care consistent with preferences were high. Cost data was inadequate to draw conclusions. While physician management, patient values, disease and treatment factors may also impact EOL choices, pilot data indicates that expanding ACP through trained RNs and LCSWs serves to normalize ACP as an integral component of quality care and promote outcomes congruent with GOC. [Table: see text]