Improving Advance Care Planning Research Articles

Improve Advance Care Planning: A Brief Report Discussing Goals of Care Interventions to Improve Communication Among Health Care Teams and Patients Maximizing the Use of the Electronic Health Record Tools.

Introduction: A key element of advance care planning (ACP) is the goals of care (GOC) conversation between the provider and the patient. The value of meaningful GOC conversations for the patient, provider, and health care institution is well documented. However, if the GOC documentation is buried in the medical record, not well defined, or poorly documented, that value is squandered. The Improvement Process: Interventions were implemented with oncology physicians and nurse practitioners (NPs). These included education, system reform including improving the ease and consistency of documentation of ACP, and regular feedback. Results: Participants reported increased confidence in communication skills about GOC conversations postworkshops. Data results for the tracked metrics, health care power of attorney, code status, and GOC, all showed improvement. Conclusion: Physicians and NPs recognized the importance of GOC conversations as part of ACP. Considerable progress was made by focusing on GOC conversations, maximizing information technology, participating in coaching, and ongoing data monitoring.

Engaging stakeholders to retrospectively discern implementation strategies to support program evaluation: Proposed method and case study

BackgroundAvailability of evidence-based practices (EBPs) is critical for improving health care outcomes, but diffusion can be challenging. Implementation activities increase the adoption of EBPs and support sustainability. However, when implementation activities are a part of quality improvement processes, evaluation of the time and cost associated with these activities is challenged by the need for a correct classification of these activities to a known taxonomy of implementation strategies by implementation actors. DesignObservational study of a four-stage, stakeholder-engaged process for identifying implementation activities and estimating the associated costs. ResultsA national initiative in the Veterans Health Administration (VHA) to improve Advance Care Planning (ACP) via Group Visits (ACP-GV) for rural veterans identified 49 potential implementation activities. Evaluators translated and reduced these to 14 strategies used across three groups with the aid of implementation actors. Data were collected to determine the total implementation effort and applied cost estimates to estimate the budget impact of implementation for VHA. LimitationsRecall bias may influence the identification of potential implementation activities. ConclusionsThis process improved understanding of the implementation effort and allowed estimation of ACP-GV 's budget impact. ImplicationsA four-stage, stakeholder-engaged methodology can be applied to other initiatives when a pragmatic evaluation of implementation efforts is needed.

Improving Advance Care Planning for Hospitalized Patients With Heart Failure.

Advance care planning (ACP) is a valuable and proven approach for enhancing end-of-life communication and quality of life for individuals with heart failure (HF) and their family members. However, the adoption of ACP in practice is still lower than desired. According to University of California, Irvine Medical Center HF metrics, only 15.3% of hospitalized HF patients had completed ACP documentation before discharge, as recorded in the electronic medical record (EMR). This quality improvement project aimed to investigate whether the rate of ACP completion could be increased by utilizing EMR reminders to health care teams regarding individual patients. Personalized reminders were sent to providers for each hospitalized patient diagnosed with HF, who did not have existing ACP documentation in the EMR, to encourage completion of ACP documentation. Our findings have shown that, during the three-month intervention period, the average ACP completion rate was 21.0%. This represents a 5.7% absolute increase in ACP completion compared to the six months before our intervention (15.3%); a relative increase of 37.3%. Direct message reminders to providers prove to be an effective method for enhancing ACP completion among this specific patient group.

Outcomes of a 3-Year Quality Improvement Study to Improve Advance Care Planning in Patients With Decompensated Cirrhosis.

To report outcomes of a 3-year quality improvement pilot study to improve advance directive (AD) completion. The pilot consisted of champions, education, electronic health record templates, and workflow changes. We assessed changes, predictors, and effects of AD completion. The pilot led to greater (8.3%-36%) and earlier AD completion, particularly among those divorced, with alcohol-associated liver disease, and with higher Model of End-Stage Liver Disease-Sodium score. Decedents whose AD specified nonaggressive goals experienced lower hospital lengths of stay. Advance care planning initiatives are feasible and may reduce health care utilization among decedents requesting less aggressive care.

Planning for Your Advance Care Needs (PLAN): A Communication Intervention to Improve Advance Care Planning among Latino Patients with Advanced Cancer.

The goal of this study was to develop and optimize an intervention designed to address barriers to engagement in advance care planning (ACP) among Latino patients with advanced cancer. The resulting intervention, titled Planning Your Advance Care Needs (PLAN), is grounded in theoretical models of communication competence and sociocultural theory. An initial version of the PLAN manual was developed based on a prior intervention, Ca-HELP, that was designed to improve communication around pain among cancer patients. PLAN uses this framework to coach patients on how to plan for and communicate their end-of-life care needs through ACP. In the present study, feedback was obtained from key stakeholders (n = 11 patients, n = 11 caregivers, n = 10 experts) on this preliminary version of the PLAN manual. Participants provided ratings of acceptability and feedback around the intervention content, format, design, modality, and delivery through quantitative survey questions and semi-structured qualitative interviews. Results indicated that the PLAN manual was perceived to be helpful and easy to understand. All stakeholder groups liked the inclusion of explicit communication scripts and guidance for having conversations about ACP with loved ones and doctors. Specific feedback was given to modify PLAN to ensure it was optimized and tailored for Latino patients. Some patients noted reviewing the manual motivated engagement in ACP. Feedback from stakeholders resulted in an optimized, user-centered version of PLAN tailored to Latino patients. Future research will examine the acceptability, feasibility, and potential efficacy of this intervention to improve engagement in ACP.

Quality and Satisfaction With Advance Care Planning Conversations Among English- and Spanish-Speaking Older Adults.

Background: Little is known about the patient-reported quality of and satisfaction with advance care planning (ACP) conversations with surrogates and clinicians among English- and Spanish-speaking older adults, or the potential disparities associated with ACP communication satisfaction. Objectives: To determine patients' perceived quality of and satisfaction with ACP surrogate/clinician conversations and associated patient characteristics. Design: Cross-sectional baseline data were used from two ACP trials, 2013-2017. Outcomes included self-reported ACP conversation quality ("general" vs. "detailed") and communication satisfaction (5-point Likert scale). Associations were determined by chi-squared and t-tests. Setting/Subjects: Subjects were primary care patients ≥55 years with chronic/serious illness in the United States. Results: Of 1398 patients, mean age was 65.6 years (±7.7), 46% women, 32% Spanish speaking, 34% had limited health literacy, and 589 (42%) reported conversations with surrogates and 216 (15%) with clinicians. Of these, less than half rated the conversations as detailed high quality (clinician: 43%; surrogate: 37%). Five-point communication satisfaction scores were higher with detailed versus general conversations (e.g., surrogates: 4.4 vs. 4.1, p = 0.001; clinicians: 4.4 vs. 4.2, p = 0.18) and more often reported by men versus women [(4.4 (0.8) vs. 4.0 (1.0), p = 0.003]; those with adequate versus limited health literacy [4.4 (0.8) vs. 4.0 (0.9), p = 0.002]; and English versus Spanish speakers [4.5 (0.7) vs. 3.5 (0.9), p < 0.001]. Conclusions: Among English- and Spanish-speaking older adults, ACP conversations were infrequent and most were general in quality. Higher quality detailed conversations resulted in greater communication satisfaction. Interventions are needed to improve conversation quality, particularly for Spanish-speaking patients and those with limited health literacy. Trial Registrations: ClinicalTrials.gov identifiers: "Improving Advance Care Planning by Preparing Diverse Seniors for Decision Making (PREPARE)" NCT01990235 and "Preparing Spanish-Speaking Older Adults for Advance Care Planning and Medical Decision Making (PREPARE)" NCT02072941.

Improving Advance Care Planning Documentation Among Latinx Patients on an Inpatient Medicine Teaching Service (QI113)

Improving Advance Care Planning Documentation Among Latinx Patients on an Inpatient Medicine Teaching Service (QI113)

A Scoping-Review of Nurse-Led Research to Improve Advance Care Planning: A Call to Action (GP747)

A Scoping-Review of Nurse-Led Research to Improve Advance Care Planning: A Call to Action (GP747)

Know Their Wishes: A Quality Improvement Project on Improving Advance Care Planning (ACP) in Cancer Patients

Know Their Wishes: A Quality Improvement Project on Improving Advance Care Planning (ACP) in Cancer Patients

Leveraging Value-Based Purchasing to Improve Advance Care Planning.

Advance care planning (ACP) is an important component of person-centered care for older adults in nursing facilities. Although nursing facilities have a statutory obligation to offer ACP to residents, there are no minimum training requirements for staff. Lack of consistent ACP training contributes to significant variability in ACP conversation quality, inaccurate or incomplete documentation of preferences, and infrequent re-evaluation of prior decisions. Indiana added ACP training for nursing facility staff to the Value-Based Purchasing formula for 2019. Facilities received 5 points (of a 100-point total formula) if at least one staff member completed the designated ACP training during the year. ACP Foundations Training was developed by faculty at Indiana University and made available to all Indiana nursing facilities. A total of 1,087 participants, representing 94.2% (501 of 532) Indiana nursing facilities, completed the training. Approximately every participant (99.4%) agreed that the training had practical value. This academic-government partnership was successful in providing basic information about ACP to staff at most nursing facilities across Indiana and offers a model for states to provide critical educational content to nursing facility staff by incentivizing training. [Journal of Gerontological Nursing, 48(2), 31-35.].

S1081 Outcomes of a Quality Improvement Initiative to Improve Advance Care Planning Among Outpatients With Decompensated Cirrhosis

Introduction: Advance care planning (ACP) aims to provide care at the end of life (EOL) that is consistent with a patient’s wishes, but it is infrequently performed in patients with decompensated cirrhosis. We implemented a quality improvement (QI) initiative in a hepatology fellows clinic at a major tertiary medical center with the goal of increasing advance directive (AD) completion among patients with decompensated cirrhosis. The goal of this analysis is to describe factors related to successful AD completion and preliminary effects of AD completion on EOL outcomes. Methods: The QI intervention, consisting of provider education, electronic health record templates, and standardized workflows, was conducted between November 2018 and March 2021. We performed a retrospective chart review of adult patients with decompensated cirrhosis seen during this period. We collected data on whether an AD was successfully completed and type of AD (first completed, if multiple). We also assessed location of death and receipt of hospice care among decedent patients. Descriptive statistics and univariate logistic regression were performed using STATA 14.2. Results: A total of 120 patients with decompensated cirrhosis were seen during the QI intervention. Our cohort was mostly male (62%), Latino (55%), Medicaid-insured (70%) and non-transplant candidates (86%). AD completion improved from 8% (N=10) to 44% (N=53) by the end of the study period. Most ADs were completed in the outpatient setting (N=38, 72%) and were healthcare proxy designation forms (N=41, 77%). A diagnosis of NASH (OR: 4.25, 95% CI: 1.11-16.2) and divorced marital status (OR: 10.23, CI: 2.04-51.3) were the only factors associated with successful AD completion. Seventeen (14%) patients died during the study period, of which 12 (71%) had an AD. Decedents with an AD were more likely overall to receive hospice (67% vs. 20%) and die under hospice care (42% vs. 20%). Conclusion: Following our QI intervention, 44% of patients with decompensated cirrhosis had an AD, which were largely health care proxy forms completed in the outpatient setting. No significant disparities in AD completion by age, gender, or race were observed from our intervention. AD completion was associated with higher rates of receiving hospice among decedents. These findings suggest benefits of AD completion on EOL care in this population.Table 1.: AD=advance directive, SD=standard deviation, LT=liver transplant, MOLST=medical order for life-sustaining treatment, DNR=do-not-resuscitate order.

Educational Interventions to Improve Advance Care Planning Discussions, Documentation and Billing

Educational Interventions to Improve Advance Care Planning Discussions, Documentation and Billing

Improving Advance Care Planning Documentation Using Reminders to Patients and Physicians: A Longitudinal Study in Primary Care.

Documenting advance care planning (ACP) in primary care requires multiple triggers. New Medicare codes make it easier for providers to bill for these encounters. This study examines the use of patient and provider reminders to trigger advance care planning discussions in a primary care practice. Secondary outcome was billing of new ACP billing codes. Patients 75 years and older scheduled for a primary care appointment were screened for recent ACP documentation in their chart. If none was found, an electronic or mail message was sent to the patient, and an electronic message to their provider, about the need to have discussion at the upcoming visit. Chart review was performed 3 months after the visit to determine if new ACP discussion was documented in the chart. In the 3 months after the reminder had been sent to patients and providers, new ACP documentation or billing was found in 28.8% of the patients. Most new documentation was health care decision maker (75.6% of new documentation) with new DNR orders placed for 32.3% of these patients. The new Medicare billing code was filled 10 times (7.8%). Reminders sent to both patients and providers can increase documentation of ACP during primary care visits, but rarely triggers a full ACP conversation.

117 Hospital @Home and the Amber Care Bundle: Introducing the Concept of Uncertainty of Survival to Improve Advance Care Planning

Abstract Introduction GSTT@home is a hospital@home providing multi-disciplinary acute care in peoples’ homes throughout Lambeth and Southwark. AMBER is an internationally recognised care bundle to improve care for hospital inpatients where survival is uncertain. The bundle prompts recognition of survival uncertainty, communication and advance care planning (ACP)- principles relevant to many hospital@home patients. This quality improvement project aimed to embed these principles into GSTT@home by adapting AMBER to this community setting. Methods Cycle 1 Plan- Determine whether @home patients might benefit from principles of AMBER. Do and Study- Audit patients &amp;gt;80 years that died within a 3-month period after @home admission (January–June 2018); one in 10 patients died (10.9%), median age 82 and median CFS 8. Act- Inpatient AMBER bundle adapted for @home setting to systemically identify and prompt ACP. Cycle 2 Plan and Do- AMBER@Home bundle formally introduced and piloted with @home, education using posters and lanyard cards. Study Audit use of AMBER@Home for patients &amp;gt;80 years who died within three months of discharge from @home (August–October 2019). Act- AMBER@Home incorporated into daily handover document. Cycle 3 Plan and Do- Further education embedded AMBER@Home, increased consultant and GP support. Study- Use of AMBER@Home re-audited as above for November 2019–January 2020. Conclusions Using AMBER@Home appears to have changed practice without the AMBER bundle being formally used. Throughout 3 audit cycles there was a steady increase in ACP. Future planned interventions include appointing a frailty nurse to @home team to further embed AMBER@Home, distributing lanyard cards more often and using “Coordinate My Care” to improve accessibility to ACP decisions including PEACE.

Cultural and Institutional Considerations in Advance Care Planning in Long-Term Care Settings

Advance Care Planning (ACP) is a process that supports individual’s understanding and sharing of personal values, life goals, and preferences regarding future medical care, so that they obtain care consistent with these during serious and chronic illness. While ACP is important for all, it is especially so for people who fall outside traditional, western, heteronormative contexts (e.g. who belong to ethnic, racial and/or sexual/gender minorities). This symposium draws from research conducted by the Diversity Access Team [part of a national project iCAN-ACP Improving Advance Care Planning for Frail Elderly Canadians]. The first paper presents results from focus groups conducted with loved ones of South Asian, Chinese and Lesbian, Gay, Bisexual, and Transgender (LGBT) older adults living in care homes; issues identified as barriers include starting ACP conversations too late (“my husband has severe dementia”), lack of consideration of cultural traditions and, in the case of LGBT older adults, their non-family support networks. The second paper draws from focus groups with care home staff, implicating their own training as a barrier to assisting residents/families with ACP as well as resident, family, institutional and cultural influences. A third paper reports on an educational intervention designed to increase staff understanding of ACP and comfort in assisting residents/families with ACP. The fourth paper reports feedback received on two ACP planning tools, reflecting the importance of minority group representation in visuals and text. Together, these papers underscore the importance of taking culture into consideration in framing and discussions of fostering ACP among minority populations.

Effect of Behavior Change Techniques Targeting Clinicians to Improve Advance Care Planning in Heart Failure: A Systematic Review and Meta-Analysis

National and international guidelines recommend advance care planning (ACP) for patients with heart failure. But clinicians seem hesitant to engage with ACP. Our aim was to identify behavioral interventions with the greatest potential to engage clinicians with ACP in heart failure. A systematic review and meta-analysis. We searched CINAHL, Cochrane Central Register of Controlled Trials, Database of Systematic Reviews, Embase, ERIC, Ovid MEDLINE, Science Citation Index, and PsycINFO for randomized controlled trials (RCTs) from inception to August 2018. Three reviewers independently extracted data, assessed risk of bias (Cochrane risk of bias tool), the quality of evidence (Grading of Recommendation Assessment, Development, and Evaluation), and intervention synergy according to the behavior change wheel and behavior change techniques (BCTs). Odds ratios (ORs) were calculated for pooled effects. Of 14,483 articles screened, we assessed the full text of 131 studies. Thirteen RCTs including 3,709 participants met all of the inclusion criteria. The BCTs of prompts/cues (OR: 4.18; 95% confidence interval [CI]: 2.03-8.59), credible source (OR: 3.24; 95% CI: 1.44-7.28), goal setting (outcome; OR: 2.67; 95% CI: 1.56-4.57), behavioral practice/rehearsal (OR: 2.64; 95% CI: 1.50-4.67), instruction on behavior performance (OR: 2.49; 95% CI: 1.63-3.79), goal setting (behavior; OR: 2.12; 95% CI: 1.57-2.87), and information about consequences (OR: 2.06; 95% CI: 1.40-3.05) showed statistically significant effects to engage clinicians with ACP. Certain BCTs seem to improve clinicians' practice with ACP in heart failure and merit consideration for implementation into routine clinical practice.

Improving Advance Care Planning Readiness Among Nursing Students.

Improving Advance Care Planning Readiness Among Nursing Students.

Empowering Older Adults to Discuss Advance Care Planning During Clinical Visits: The PREPARE Randomized Trial.

A patient-directed, online program (PREPARE for Your Care [PREPARE]; prepareforyourcare.org) has been shown to increase advance care planning (ACP) documentation. However, the mechanisms underlying PREPARE are unknown. Our objectives were to compare the efficacy of PREPARE plus an easy-to-read advance directive (AD) vs an AD alone to increase active patient participation in ACP discussions during clinic visits and to examine effects of active patient participation on ACP documentation. Audio recordings of postintervention primary care visits from two randomized trials (2013-2016). Seven primary care clinics at a veterans affair and safety-net hospital in San Francisco, CA. English- and Spanish-speaking adults, aged 55 years and older, with two or more chronic/serious conditions. PREPARE plus an easy-to-read AD or an AD alone. The primary outcome was the number of active patient participation utterances about ACP (eg, asking questions, stating preferences) measured by the validated Active Patient Participation Coding Scheme. We examined differences in utterances by study arm using mixed effects negative binomial models and utterances as a mediator of PREPARE's effect on documentation using adjusted logistic regression. Models were adjusted for health literacy, prior care planning, and clinician. Among 393 participants, the mean (SD) age was 66 (8.1) years, 120 (30.5%) had limited health literacy, and 99 (25.2%) were Spanish speaking. PREPARE plus the AD resulted in 41% more active patient participation in ACP discussions compared with the AD alone (mean [SD] = 10.1 [16.8] vs 6.6 [13.4] utterances; incidence rate ratio = 1.41; 95% confidence interval = 1.00-1.98). For every additional utterance, participants had 15% higher odds of ACP documentation, and active patient participation accounted for 16% of PREPARE's effect on documentation. The PREPARE program and easy-to-read AD empowered patients to actively participate in ACP discussions during clinical visits more than the AD alone. Increased activation was associated with increased ACP documentation. Therefore, PREPARE may mitigate barriers to ACP among English- and Spanish-speaking older adults. ClinicalTrials.gov identifiers: "Improving Advance Care Planning by Preparing Diverse Seniors for Decision Making (PREPARE)" NCT01990235 and "Preparing Spanish-Speaking Older Adults for Advance Care Planning and Medical Decision Making (PREPARE)" NCT02072941. J Am Geriatr Soc 68:1210-1217, 2020.

Nurse Practitioner-Led Education: Improving Advance Care Planning in the Skilled Nursing Facility

The Advance Care Planning (ACP) note is a critical component for guiding the care of patients in the Skilled Nursing Facility (SNF). Although ACP documentation is essential, it often is not completed in the SNF. The purpose of the project was to increase the number of ACP notes for patients admitted to 13 SNFs in Southeastern Minnesota. Prior to intervention, the ACP note was not consistently completed by the Nurse Practitioner (NP) or Physician Assistant (PA) in the SNF. The aim of the Quality Improvement (QI) project was to increase ACP note completion rates by 50% and increase satisfaction and knowledge with the ACP process amongst NPs and PAs over a 12-week period after the administration of a one-hour ACP education session. By improving the ACP process, patients can participate in a positive end-of-life experience and receive medical care that is consistent with their values, goals and preferences. The hypothesis for this project was that a structured ACP process would increase the number of ACP notes completed compared to current processes. A secondary outcome was that structured ACP process would increase NP and PA satisfaction and knowledge with completing ACP notes. The design was a QI project that addressed the ACP process in 13 SNFs in Southeastern Minnesota. A convenience sample (N=10) of NP/PA providers completed a pre and post ACP education intervention survey. On all six survey questions, a general increase in mean value was demonstrated. Question two, seven and eight demonstrated the greatest increase in mean value score of (0.7, 1.2, and 0.9) respectively. A Wilcoxon signed-rank test elicited significant change in knowledge (p=0.037), understanding of ACP note billing (p ≤ 0.001), and satisfaction with ACP note documentation (p=0.004). Unfortunately, the QI project demonstrated a 2% decrease in ACP note documentation in the post-intervention phase. Although there was not a significant change in the ACP note completion rates, an improvement in NP/PA knowledge and satisfaction was demonstrated through ACP education session.

Improving Advance Care Planning in Outpatients With Decompensated Cirrhosis: A Pilot Study

BackgroundDespite significant morbidity and mortality among patients with decompensated cirrhosis, reported rates of advance directive (AD) completion and goals of care discussions (GCDs) between patients and providers are very low. We aimed to improve these rates by implementing a hepatologist-led advance care planning (ACP) intervention. MeasuresRates of AD and GCD completion, as well as self-reported barriers to ACP. InterventionProvider-led ACP in patients with decompensated cirrhosis without a prior documented AD. OutcomesSixty-two patients were seen over 115 clinic visits. After the intervention, AD completion rates increased from 8% to 31% and GCD completion rates rose from 0% to 51%. Women (P = 0.048) and nonmarried adults (P = 0.01) had greater changes in AD completion compared to men and married adults, respectively. Needing more time during visits was seen as the major barrier to ACP among providers. Conclusions/Lessons LearnedAddressing provider and system-specific barriers dramatically improved documentation rates of ACP.