Documentation Of Advance Directives Research Articles

Patient Navigator Intervention to Improve Palliative Care Outcomes for Hispanic Patients With Serious Noncancer Illness

Disparities persist across the trajectory of serious illness, including at the end of life. Patient navigation has been shown to reduce disparities and improve outcomes for underserved populations. To determine the effectiveness of a lay patient navigator intervention, Apoyo con Cariño, in improving palliative care outcomes among Hispanic patients. This was a multicenter randomized clinical trial that took place across academic, nonprofit, safety-net, and community health care systems in urban, rural, and mountain/frontier regions of Colorado from January 2017 to January 2021. Self-identifying Hispanic adults with serious noncancer medical illness and limited prognosis were recruited. Data were collected and analyzed from July 2022 to July 2023. Participants randomized to the intervention group received 5 home visits from a bilingual, bicultural lay patient navigator; participants randomized to control received care as usual. Both groups received culturally tailored educational materials. Investigators/outcome accessors remained blinded to participant assignment. Change in score from baseline to 3 months on the Functional Assessment of Chronic Illness Therapy (FACIT) General quality of life (QOL) scale (primary outcome), Advance Care Planning (ACP) Engagement Survey, Brief Pain Inventory, Edmonton Symptom Assessment Scale, and FACIT Spiritual Well-Being subscale; at 6 months, advance directive (AD) documentation; and at 46 months or death, hospice utilization and length of stay, as well as aggressiveness of care at end of life. Of 209 patients enrolled (mean [SD] age, 63.6 [14.3] years; 108 [51.7%] male), 105 patients were randomized to control and 104 patients to the intervention. There were no statistically significant differences in the change in mean (SD) QOL score between the intervention and control groups (5.0 [16.5] vs 4.3 [15.5]; P = .75). Participants in the intervention group, compared with the control group, had statistically significant greater increases in mean (SD) ACP engagement (0.8 [1.3] vs 0.1 [1.4]; P < .001) and were more likely to have a documented AD (62 of 104 [59.6%] vs 28 of 105 [26.9%]; P < .001). There were no statistically significant differences in mean (SD) change in pain intensity score (0-10) between patients in the intervention group compared with control (-0.4 [2.6] vs -0.5 [2.8]; P = .79), nor pain interference (-0.2 [3.7] vs -0.4 [3.7]; P = .71). Patients receiving the intervention were more likely to be referred to hospice compared with patients receiving control (19 of 43 patients [44.2%] vs 7 of 33 patients [21.2%]; P = .04) and less likely to receive aggressive care at end of life (27 of 42 patients [64.3%] vs 28 of 33 patients [84.8%]; P = .046). In this randomized clinical trial, a culturally tailored patient navigator intervention did not improve QOL for patients. However, the intervention did increase ACP engagement, AD documentation, and hospice utilization in Hispanic persons with serious medical illness. ClinicalTrials.gov Identifier: NCT03181750.

PRELIMINARY FINDINGS OF THE SHARING CHOICES INTERVENTION ON PRIMARY OUTCOME MEASURES

Abstract A cluster randomization approach was applied to 55 primary care practices across two health systems. A 1:2 randomization design resulted in 19 practices being randomized to the SHARING Choices intervention condition and 36 practices randomized to a usual care control condition. The primary outcome variables include documentation of an advance directive (AD) or medical orders for life-sustaining treatment in the electronic health record (EHR) within 12 months of exposure to the intervention for all patients and receipt of potentially burdensome care within 6 months of death for patients who die with a serious illness diagnosis. At the time of this abstract submission, preliminary data on AD documentation in the EHR have been analyzed for one of the two health systems. In that health system, among 8,350 patients in intervention practices, AD documentation in the EHR increased from 19.2% to 25.1% one year later, compared to increases from 15.7% to 17.9% among 19,179 patients in control practices. This markedly greater increase for patients in intervention practices was highly significant statistically in a multilevel logistic regression model that took patient clustering within practices into account (adjusted odds ratio = 2.25; 95% confidence interval = 2.01, 2.51; p &amp;lt; 0.001). The SHARING Choices intervention, therefore, more than doubled the odds of having an AD added to the EHR within one year. Preliminary findings on this outcome from the other health system and other outcomes from both health systems will be analyzed in the months ahead and presented at the GSA meeting in November.

Early Integrated Palliative Care Within a Surgical Oncology Clinic

Advance directive (AD) designation is an important component of advance care planning (ACP) that helps align care with patient goals. However, it is underutilized in high-risk surgical patients with cancer, and multiple barriers contribute to the low AD designation rates in this population. To assess the association of early palliative care integration with changes in AD designation among patients with cancer who underwent surgery. This cohort study was a retrospective analysis of a prospectively maintained registry of adult patients who underwent elective surgery for advanced abdominal and soft tissue malignant tumors at a surgical oncology clinic in a comprehensive cancer center with expertise in regional therapeutics between June 2016 and May 2022, with a median (IQR) postoperative follow-up duration of 27 (15-43) months. Data analysis was conducted from December 2022 to April 2023. Integration of ACP recommendations and early palliative care consultations into the surgical workflow in 2020 using electronic health records (EHR), preoperative checklists, and resident education. The primary outcomes were AD designation and documentation. Multivariable logistic regression was performed to assess factors associated with AD designation and documentation. Among the 326 patients (median [IQR] age 59 [51-67] years; 189 female patients [58.0%]; 243 non-Hispanic White patients [77.9%]) who underwent surgery, 254 patients (77.9%) designated ADs. The designation rate increased from 72.0% (131 of 182 patients) before workflow integration to 85.4% (123 of 144 patients) after workflow integration in 2020 (P = .004). The AD documentation rate did not increase significantly after workflow integration in 2020 (48.9% [89 of 182] ADs documented vs 56.3% [81 of 144] ADs documented; P = .19). AD designation was associated with palliative care consultation (odds ratio [OR], 41.48; 95% CI, 9.59-179.43; P < .001), palliative-intent treatment (OR, 5.12; 95% CI, 1.32-19.89; P = .02), highest age quartile (OR, 3.79; 95% CI, 1.32-10.89; P = .01), and workflow integration (OR, 2.05; 95% CI, 1.01-4.18; P = .048). Patients who self-identified as a race or ethnicity other than non-Hispanic White were less likely to have designated ADs (OR, 0.36; 95% CI, 0.17-0.76; P = .008). AD documentation was associated with palliative care consulation (OR, 4.17; 95% CI, 2.57- 6.77; P < .001) and the highest age quartile (OR, 2.41; 95% CI, 1.21-4.79; P = .01). An integrated ACP initiative was associated with increased AD designation rates among patients with advanced cancer who underwent surgery. These findings demonstrate the feasibility and importance of modifying clinical pathways, integrating EHR-based interventions, and cohabiting palliative care physicians in the surgical workflow for patients with advanced care.

Disparities in Advance Directive Documentation for Rural-Dwelling Persons With Lung Cancer.

Purpose: Advance directives (AD) are recommended for persons with lung cancer, yet few studies have investigated AD and healthcare power of attorney (HCPOA) documentation for this population in rural regions of the United States. The purpose of this study was to examine demographic and clinical factors associated with AD and HCPOA documentation for persons with lung cancer in rural eastern North Carolina (ENC). Methods: A cross-sectional retrospective chart review was conducted to collect demographic and clinical data from electronic health records from 2017 to 2021 at a tertiary cancer center and regional satellite sites in ENC. Descriptive statistics and Chi-Square Tests of Independence were used for data analysis. Findings: The sample's mean age was 69.5years (n = 402, SD = 10.5, range = 28 - 92). Most participants were male (58%) and had a smoking history (93%). Consistent with regional population statistics, 32% of persons were black, and 52% lived in rural counties. Just 18.5% of the sample had a documented AD and 26% had a healthcare power of attorney. Black persons had significantly lower AD and HCPOA (P < .001) documentation than white persons. Rural-dwellers had significantly lower HCPOA documentation than urban-dwellers (P = .03). For all other variables, no significant differences were found. Conclusions: These findings suggest that AD and HCPOA documentation are low for persons with lung cancer in ENC, particularly for black persons and rural-dwellers. This disparity highlights the need for enhanced advance care planning (ACP) access to and outreach in the region.

A Letter to Your Care Providers: Implementation and Analysis of a Letter-based Advance Care Planning Initiative for Gynecologic Oncology Patients.

To determine the impact of a letter-based advance care planning (ACP) healthcare improvement (HI) initiative on rates of ACP conversations and documentation among gynecologic oncology (GO) inpatients. An HI initiative was implemented from January to December 2020 to improve ACP documentation among GO inpatients. Patients admitted to the GO service were given ACP packets with a letter-based ACP worksheet. GO inpatients who were interested in learning more about ACP were visited by medical students trained to lead ACP conversations. ACP documentation rates in the EMR (electronic medical record) pre- and post-intervention were evaluated. Descriptive statistics were calculated. Associations between sociodemographic characteristics and ACP documentation were analyzed using logistic regression. There were 172 patients admitted in 2019 (pre-implementation cohort). Of these, 45/172 patients (26%) had an advance directive (AD) documented in their electronic medical record (EMR). Following the implementation of the ACP HI in 2020, 55/168 patients (33%) had an AD documented in their EMR. This was a 7% absolute increase and 27% relative increase from pre-intervention AD documentation rates. Increasing age was associated with an increased likelihood of having an AD in the chart (p = 0.004). Married women were less likely to have an AD in their chart (p = 0.05). An HI utilizing a letter-based ACP packet given to GO inpatients improved AD documentation in the EMR. This HI offers a unique method for introducing ACP to patients. More work is needed to improve the occurrence and documentation of ACP conversations.

Factors Associated with Advance Directives Documentation: A Nationwide Cross-Sectional Survey of Older Adults in Korea.

Advance directives (ADs) can support autonomy in making healthcare decisions and minimize unnecessary discomfort during the treatment process at the end of life (EOL). This study aimed to investigate the factors that influence AD documentation among community-dwelling older adults. We used data from the National Survey of Older Koreans which was conducted nationwide in 2020. Data from participants aged 65 years or older were extracted using stratified multistage cluster sampling and the survey was conducted through one-on-one interviews. A total of 9920 older adults were included in this study: 421 respondents (4.7%) claimed that they had prepared for AD. Multivariable logistic regression analysis showed that being 75 years or older, having higher educational attainment, higher income, having any chronic disease(s), being screened for dementia in the past, being against futile life-sustaining treatment, taking a lecture on death and being registered for organ donation were positively associated with AD. Furthermore, when health was rated as average, it was associated with reduced odds of AD documentation compared when health was rated as good. These results suggest that more targeted efforts are required to promote EOL discussions among older adults.

Advance Directive Documentation in a Huntington's Disease Clinic: A Retrospective Chart Review.

Background:Advance care planning (ACP) benefits patients and caregivers, yet it is underutilized and little is known about ACP in Huntington’s disease (HD) clinics. This study sought to determine the percentage of charts with AD documentation within an HD clinic.Methods:A retrospective chart review was conducted on a randomly selected sample of charts within an HD clinic. HD patients ≥18 y/o with a positive genetic test (≥40 CAG repeats) seen between January 2018 and June 2021 were included. Charts were reviewed for documentation of ADs either in provider notes or in the electronic medical records (EMR).Results:Ninety-one charts were reviewed (n = 91). Twenty-two charts (24.2%) mentioned a completed AD within a provider’s note; however, only nine (9.9%) had an AD available in the EMR. Cognitive status, primary insurance type, presence of dysphagia, and stage of disease were associated with documentation of completed ADs within a provider’s note.Discussion:The rate of completed ADs mentioned in a provider’s note (24.2%) was significantly lower than rates of AD completion in a previous study within the HD population (38%). Additional studies focused on improving rates AD completion are needed.HighlightsMost patients with Huntington’s disease do not have documentation of completed advance directives (ADs) within their medical chart. In a retrospective chart review 24.2% of patients seen in a specialty HD clinic had documentation of ADs in a provider’s note and 9.9% had ADs available within the EMR.

Implementation and Effectiveness of Integrating Palliative Care Into Ambulatory Care of Noncancer Serious Chronic Illness: Mixed Methods Review and Meta-Analysis.

To perform a mixed methods review to evaluate the effectiveness and implementation of models for integrating palliative care into ambulatory care for US adults with noncancer serious chronic illness. We searched 3 electronic databases from January 2000 to May 2020 and included qualitative, mixed methods studies and randomized and nonrandomized controlled trials. For each study, 2 reviewers abstracted data and independently assessed for quality. We conducted meta-analyses as appropriate and graded strength of evidence (SOE) for quantitative outcomes. Quantitative analysis included 14 studies of 2,934 patients. Compared to usual care, models evaluated were not more effective for improving patient health-related quality of life (HRQOL) (standardized mean difference [SMD] of 4 of 8 studies, 0.19; 95% CI, ‒0.03 to 0.41) (SOE: moderate) or for patient depressive symptom scores (SMD of 3 of 9 studies, ‒0.09; 95% CI, ‒0.35 to 0.16) (SOE: moderate). Models might have little to no effect on patient satisfaction (SOE: low) but were more effective for increasing advance directive (AD) documentation (relative risk, 1.62; 95% CI, 1.35 to 1.94) (SOE: moderate). Qualitative analysis included 5 studies of 146 patients. Patient preferences for appropriate timing of palliative care varied; costs, additional visits, and travel were considered barriers to implementation. Models might have little to no effect on decreasing overall symptom burden and were not more effective than usual care for improving HRQOL or depressive symptom scores but were more effective for increasing AD documentation. Additional research should focus on identifying and addressing characteristics and implementation factors critical to integrating models to improve ambulatory, patient-centered outcomes.

Advance Care Planning and Healthcare Utilization in Patients With Amyotrophic Lateral Sclerosis: A Retrospective Chart Review.

Background: Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disorder resulting in functional decline and death. Despite recent emphases on advance care planning (ACP), low rates of documentation of ACP are seen in this population. Objectives: This study aims to determine rates of advance directive (AD) documentation and whether having a documented AD or ACP discussion affects healthcare utilization for ALS patients. Design: Retrospective chart review. Setting/Subjects: 130 patients from a multidisciplinary clinic at one U.S. tertiary care medical center. Measurements: The presence of a completed AD uploaded to the electronic medical record; the documentation of ACP discussions; and rates of percutaneous endoscopic gastrostomy (PEG) placement, tracheostomy placement, hospitalization within 2 weeks of death, death in hospital, and hospice utilization. Results: Overall rates of AD documentation in the electronic medical record were low at only 29.2%. Rates of PEG placement, tracheostomy placement, hospitalization within 2 weeks of death, death in hospital, and hospice utilization did not vary between patients with and without AD documentation. However, patients with a documented ACP conversation were more likely to have a PEG placed and to utilize hospice. Conclusions: Our study indicates that while having a documented AD is not correlated to differences in healthcare utilization in patients with ALS, the benefit of ACP in this population is in having a dedicated conversation with patients and caregivers rather than focusing on completion of a static document.

Advance Directive and POLST Documentation in Decedents With Dementia at a Memory Care Center: The Importance of Early Advance Care Planning.

To determine the frequency of and challenges to documentation of advance care planning (ACP) in people with dementia, we conducted a chart review of 746 deceased patients seen at a tertiary memory care center between 2012 and 2017. The rates of documented advance directives (ADs), Physician Order for Life-Sustaining Treatment (POLST), and Do Not Resuscitate (DNR) status were calculated from review of institutional electronic health records. Regression analysis was used to determine associations between ACP documentation and patient characteristics. At the time of death, approximately half of the patients had a documented AD and/or DNR status and 37% had a documented POLST; 30% of patients did not have any ACP documentation. Whereas most of the ADs were documented more than 5 years before time of death, POLST and DNR status were documented more frequently within 2 years of time of death. People who presented to clinic at a younger age and who primarily spoke English were more likely to have documented ADs. People living in zip codes with lower household incomes were 2-4.5 times less likely to have a POLST or DNR documentation. ACP is underutilized in people with dementia, even among those seen in a specialty memory care center. ACP should be introduced early on for people with dementia to ensure patients have a voice in their care.

Advance Directive Utilization Decreases Aggressive End-of-Life Care in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation

BackgroundAdvances in hematopoietic cell transplantation (HCT) over the past decades have led to improvements in HCT outcomes. However, allogeneic HCT continues to be associated with significant morbidity and mortality, making end-of-life (EOL) planning and management especially important in this patient population. A paucity of data exists on the utilization of advance care planning (ACP) amongst allogeneic HCT recipients, and the relationship between ACP and intensity of EOL health care utilization in these patients.MethodsWe performed a retrospective review of patients receiving allogeneic HCT at our institution from 2008 to 2015 who had subsequently died following HCT. Frequency and timing of advance directive (AD) completion were abstracted from the electronic medical record (with local chart review when possible), as were patient demographics, HCT outcomes, intensive care unit (ICU) days, use of mechanical ventilation, and location of death. Variables associated with the utilization of AD were compared using Chi-square and Wilcoxon rank sum test. Multivariable logistic regression evaluated variables associated with EOL ICU utilization.ResultsOf the 1031 patients who received allogeneic HCT during the study period, there were 422 (41%) decedents who are included in the analysis. Median age at time of transplant was 55 years (IQR, 44 to 64 years), 58% were male, and 56% were Non-Hispanic White. Acute myeloid leukemia (AML) was the most common primary disease (41%); 23% of the subjects died within 100 days of transplant date. 184 (44%) patients had an AD documented prior to death. Among patients with an AD, 105 (57%) completed the AD in the pre-transplantation period. A majority of patients (69%) indicated on the AD that if terminally ill, they did not wish to be subjected to life-prolonging treatment attempts. Race/ethnicity was significantly associated with AD documentation, with Non-Hispanic White patients documenting ADs more frequently (74%) compared to Hispanic (7%) or Asian patients (11); p= 0.0007. Patients with AD were less likely to utilize the ICU during the transplant course (41% for patients with AD versus 52% of patients without AD; p= 0.03) and also were less likely to receive mechanical ventilation at any point following transplantation (21% versus 37%; p<0.001). AD was also associated with decreased ICU utilization at the end-of-life; 25% versus 40% with and without AD were admitted to the ICU within 30 days of death (p<0.001), and 21% versus 36% with and without AD were admitted to ICU within 14 days of death (p=0.001). Amongst those with an AD, patients who indicated a wish for life-prolonging treatment attempts were significantly more likely to utilize the ICU (64% versus 35%; p=0.02) and were also more likely to have mechanical ventilation at any point after transplant (39% versus 16%; p=0.02). Compared to patients without AD, patients with AD were more likely to die at home or in hospital as opposed to in the ICU (p=0.03).Conclusion:Our results suggest that adoption of a systematic practice to standardize advance directive documentation as part of allogeneic HCT planning has the potential to significantly reduce ICU utilization and mechanical ventilation while improving quality of care at end-of-life in HCT recipients. Culturally sensitive approaches that focus on what matters most to the patient may help ethnic minority patients complete ACP. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Improving end of life care with advance care planning in a rural cancer center.

e18637 Background: We discovered four out of five Medical Oncology patients admitted to the hospital December 2019 and January 2020 were discharged to hospice and died within a week. None of those patients had advance directives. In November and December 2019, all oncology patient charts were reviewed and only 7% (12/174) had advance directives. We believe an established advance directive could have helped avoid unnecessary hospitalization, improved end of life care and reduced wasteful health care costs. This led to the question: Would process changes in a rural cancer center lead to an increase in completion and documentation of Advance Directives, thereby providing more patient goal congruent care? Methods: Data collection and process mapping was performed revealing current processes and overall barriers. This was analyzed and countermeasures were developed leading to process changes and interventions. The interventions included assigning dedicated staff to “own” the advance directives education, follow up and completion, training and certification of staff, and education of the entire Cancer Center on the new process and interventions. The new process included a standardized order set to cue a referral to the dedicated staff, standardized patient education and follow up and documentation consistencies. Results: The initial data collection revealed an advance directive completion rate of 7% in new oncology patients. Process inconsistencies and communication deficiencies, with redundant screening and no follow up, created significant barriers to advance directives. Repeat data collection after creating a position for dedicated staff to educate patients and help with advance directive completion revealed a completion and documentation rate of 6% and thus, was insufficient to lead to change. When a consistent process with formal communication to the dedicated staff was implemented, improvements were noted. Our most recent data collection revealed a 36% completion and documentation rate in advance directives. Conclusions: Lack of effective advance directive programs potentially lead to end of life care incongruent with patients’ wishes and wasteful of health care resources. An advance directive ensures that if a patient is unable to clearly communicate their wishes, these wishes are still honored. In addition, the advance directive can help avoid unnecessary hospitalizations, improve end of life care and reduce wasteful health care costs. As a rural cancer center with a limited service area, we are challenged with a small sample size. Practice will be needed to ensure consistency and efficacy of the current interventions in order to support continued improvement in completion and documentation rates of advance directives. This project will be expanded to address advance directives for all patients.

Exploratory Study of Advance Care Discussions Among Chinese American and White Stage IV Cancer Patients at an American Tertiary Medical Center.

Timely advance care discussions are essential components of quality care for diverse populations; however, little is known about these conversations among Chinese American cancer patients. This exploratory study describes differences in advance care discussions and planning between Chinese American and White advanced cancer patients. We collected data for 63 Chinese American and 63 White stage IV cancer patients who died between 2013 and 2018. We compared: frequency and timing of prognosis, goals of care (GOC), and end-of-life care (EOLC) discussions in the final year of life; family inclusion in discussions; healthcare proxy (HCP) identification; do not resuscitate (DNR) order, do not intubate (DNI) order, and other advance directive (AD) completion. We did not conduct statistical tests due to the study's exploratory nature. Among Chinese American and White patients, respectively, 76% and 71% had prognosis, 51% and 56% had GOC, and 89% and 84% had EOLC discussions. Prognosis, GOC, and EOLC discussions were held a median of 34.0, 15.5, and 34.0 days before death among Chinese American and 17.0, 13.0, and 24.0 days before death among White patients. Documentation rates among Chinese American and White patients were 79% and 76% for DNRs, 81% and 71% for DNIs, 79% and 81% for HCPs, and 52% and 40% for other ADs. Findings suggest that Chinese Americans had similar rates of advance care discussions, completed conversations earlier, and had similar to higher rates of AD documentation compared to White patients. Further studies are needed to confirm our preliminary findings.

Advance Directives in the Nursing Home Setting: An Initiative to Increase Completion and Reduce Potentially Avoidable Hospitalizations

Advance directive (AD) completion can improve transitions between hospitals and skilled nursing facilities (SNF’s). One Centers for Medicare and Medicaid Services (CMS) Innovations Demonstration Project, The Missouri Quality Initiative (MOQI), focused on improving AD documentation and use in sixteen SNF’s. The intervention included education, training, consultation and improvements to discussion process, policy development, increased AD enactment, and increased community education and awareness activities. An analysis was conducted of data collected from annual chart inventories occurring over four years. Using a logistic mixed model, results indicated statistical significance (p < .001) for increased AD documentation. Greatest gains occurred at project mid-point. The relationship between having an AD and occurrence of transfer to a hospital was tested on a sample of 1,563 residents with length of stays more than 30 days. Residents who did not have an AD were 29% more likely to be transferred. A logistic regression was conducted, and the results were statistically significant (p < .02).

Integrating Palliative Care Social Workers into Subacute Settings: Feasibility of the Assessing & Listening to Individual Goals and Needs Intervention Trial.

Objectives: Determine feasibility, acceptability, and preliminary effects of the Palliative Care Social Worker-led ALIGN (Assessing & Listening to Individual Goals and Needs) intervention in older persons admitted to Skilled Nursing Facility (SNF) and their caregivers. Design: A pilot pragmatic randomized stepped wedge design of ALIGN versus usual care in three SNFs. Setting and Participants: One hundred and twenty older adults and caregivers (optional) with advanced medical illnesses. Measures: Primary outcomes were feasibility and acceptability. We collected exploratory patient-/caregiver-centered outcomes at baseline and three months and conducted a medical record review at six months to assess documentation of Advance Directives (AD). We also collected exploratory health care utilization data, including hospitalizations, mortality, and hospice utilization. Results: Of 179 patients approached, 120 enrolled (60 ALIGN patients with 15 caregivers and 60 usual care patients and 21 caregivers). Four intervention patients refused ALIGN visits, 8 patients died or discharged before initial visit, and 48 intervention patients received ALIGN visits, with ∼80% having caregivers participating in visits, regardless of caregiver study enrollment. Quantitative exploratory outcomes were not powered to detect a difference between groups. We found 91% of ALIGN patients had a completed AD in medical record compared to 39.6% of usual care patients (p < 0.001). Qualitative feedback from participants and SNF staff supported high acceptability and satisfaction with ALIGN. Conclusion and Clinical Implications: A pragmatic trial of the ALIGN intervention is feasible and preliminary effects suggest ALIGN is effective in increasing AD documentation. Further research is warranted to understand effects on caregivers and health care utilization. The current model for SNF does not address the palliative care needs of patients. ALIGN has potential to be an effective, scalable, acceptable, and reproducible intervention to improve certain palliative care outcomes within subacute settings.

Genesis of Quality Measurements to Improve the Care Delivered to Patients With Brain Metastases.

High-value and high-quality health care requires outcome measurements to inform treatment decisions, but, to our knowledge, no standardized measurements exist to evaluate brain metastases (BMs) care. We propose a set of measurements and report on their implementation in the care of patients with BMs. On the basis of a stakeholders' needs assessment and review of the literature, we identified outcome and process measurements to assess the care of patients with BMs according to treatment modality. Retrospectively, we applied these indicators of care to all patients diagnosed and treated at our institution over 2 years. We ascertained 5 outcome and 6 process measurements of relevance in the care of BMs. When applied to 209 patients (89.7%) who received cancer treatment, 77% were alive > 90 days after diagnosis. The proportion alive at 90 days after surgery, whole-brain radiation therapy (WBRT), and stereotactic radiosurgery (SRS) was 82%, 59%, and 81%, respectively. Other performance measurements included 30-day postoperative readmission rate (6%), SRS within 30 days of surgery (79%), use of memantine with WBRT (41%), advance directives within 6 months of diagnosis (53%), and palliative care consultation for patients with poor prognosis or receiving WBRT (45%). Measurements for the 24 patients (10.3%) receiving best supportive care were advance directives documentation (67%) and referral to palliative or hospice care (83%). We propose a set of measurements to apprise quality improvement efforts, inform treatment decision-making, and to use in evaluation of the performance of interdisciplinary BMs programs. Their refinement can potentially enhance the quality and value of care delivered to patients with BMs.

Perceptions of Patient Portal Use for Advance Directive Documentation among Older Adults with Multiple Chronic Conditions

Patient portals can play an innovative role in facilitating advanced care planning (ACP) and documenting advance directives (ADs) among older adults with multiple chronic conditions. The objective of this qualitative sub-study was to (1) understand older adults’ use of an ACP patient portal section and (2) obtain user-design input on AD documentation features. Although some older adults may be reluctant, participants reported likely to use a portal for ADs with proper portal design and support.

Utilizing Shared Medical Appointments to Increase Advance Directives Discussion and Documentation (QI607)

Utilizing Shared Medical Appointments to Increase Advance Directives Discussion and Documentation (QI607)

NAVIGATIONAL BARRIERS TO ADVANCE DIRECTIVE COMPLETION AMONG OLDER LATINOS WITH CHRONIC ILLNESS

This study examined navigational barriers to advance care planning (ACP) and advance directive (AD) completion among older Latinos with chronic illness. Older Latinos over the age of 50 were randomized to education only versus education plus counseling (N=61; education only n=31, education/counseling n=30). Exploratory factor analyses and logistic regression show relationships between navigational barriers, depression, anxiety and AD documentation. Barriers to ACP included difficulty understanding the doctor, fears about hearing bad news, worries about illness getting worse, and difficulties due to language, family conflict, and limited family discussions about dying. Treatment group was most significant contributing factor to AD completion (OR=4.213, CI=1.126 – 15.760, p=<.01). Findings indicate the importance of examining a variety of factors that could influence AD documentation. This study contributes to the literature by identifying the need for targeted and culturally relevant interventions that promote ACP education, counseling, communication, support, and AD documentation among older Latinos.

Documentation of Advance Directives and Code Status in Electronic Medical Records to Honor Goals of Care

Advance care planning is a process that supports conversations about the values that matter most to patients and their family members. The documentation of advance directives and code status in a patient's electronic health record (EHR) is a critical step to ensure treatment preferences are honored in the medical care received. The current approach to advanced care planning documentation in electronic medical records often remains disparate within and across EHR systems. Without a standardized format for documentation or centralized location for documentation, advance directives and even code status content are often difficult to access within electronic medical records. This case report launched our palliative care team into partnership with the Information Technology team for implementation of a centralized, standardized, longitudinal, functional documentation of advance care planning and code status in the electronic medical record system.