Initiating Advance Care Planning in Primary Care: A Model for Success

J Palliat Med. 2019 Apr;22(4):427-431. doi: 10.1089/jpm.2018.0380. Epub 2018 Nov 27.

Abstract

Background: Primary care physicians recognize the importance of advance care planning (ACP) conversations and report lack of training and time in the office to start them. Previous efforts have shown that ACP is a low-risk high-value intervention for older patients and those with life-limiting illness.

Objective: To measure the impact of physician coaching and staff training with registered nurse (RN) support and electronic medical record (EMR) enhancements on the initiation of 2000 ACP conversations in primary care.

Methods: Employing VitalTalk® physician coaching, Respecting Choices® "Last Steps" ACP facilitator training, support provided by an ACP nurse liaison and EMR customization, the intervention was introduced into 36 primary care practices with an additional EMR tool adopted by 12 of the 36.

Results: There was an increase from zero at baseline in the number of ACP conversations and a leveling out of new ACP initiated each month. A total of 7200 ACP conversations were initiated for 31 months in 36 primary care practices, and 29% of conversations had advance directives scanned into the EMR during a 10-month review period. Most ACP conversations were initiated by RN care managers. In 2017, there were 7589 more ACP conversations initiated.

Discussion/conclusion: By combining two complementary, evidenced-based curricula, providing support of a nurse liaison and designing a summary and alert in the EMR, this program exceeded its goal to initiate 2000 ACP conversations in primary care. Other health systems might consider a similar multicomponent intervention to increase ACP.

Keywords: advance care planning; best practice alert; primary care.