Background Advance care planning (ACP) is recommended for all persons to ensure that the care they receive aligns with their values and preferences. Objective Evaluate an ACP intervention developed to better meet the needs and priorities of persons with chronic diseases, including mild cognitive impairment. Research Design A year-long, pre-post intervention employing lay community health workers (care coordinator assistants [CCAs]) trained to conduct and document ACP conversations with patients during home health visits with pre/post evaluation. Subjects The 818 patients were 74.2 years old (mean); 78% women; 51% African American; 43% Caucasian. Measures Documentation of ACP conversation in EHR fields and health care utilization outcomes. Results In this target population ACP documentation rose from 3.4% (pre-CCA training) to 47.9% (post) of patients who had at least one discussion about ACP in the EHR. In the one-year pre-intervention period, there were no differences in admissions, emergency department (ED) visits, and outpatient visits between patients who did and did not have ACP discussion. After adjusting for prior hospitalization and ED use histories, ACP discussions were associated with a 34% less probability of hospitalization (HR = 0.66, 95% CI 0.45–0.97), and similar effects are apparent on ED use independent of age and prior ED use effects. Conclusions Patients with chronic diseases including mild cognitive impairment can engage in ACP conversations with trusted home health care providers. Having ACP conversation is associated with significant reduction in seeking urgent health care and in hospitalizations.

Background Community health workers (CHWs) can engage elderly persons in advance care planning (ACP) conversations. Objective We report how trained CHWs used Go Wish cards (GWR cards) to identify patients’ highest priority preferences and evaluated whether engaging in ACP conversations was associated with subsequent health care utilization. Design A one-year long, pre-post longitudinal design was used to evaluate our educational intervention using mixed-methods. Patients 392 patients (mean of 73.3 years, 82% women, 48% African American, 43% Caucasian) enrolled in the Aging Brain Care (ABC) program and participated in ACP discussions with CHWs. Intervention We expanded the role of the ABC’s CHW, who work directly with individuals and caregivers during home visits to monitor bio-psycho-social needs, to include ACP conversations. Main Measures The CHWs received ACP training, practice with tools such as GW R cards, and support from an electronic health record (EHR) clinical decision support tool. Quantitative measures of patients’ ACP preferences and health care utilization were abstracted from the EHR. Qualitative data about patients’ perceptions of CHWs in facilitating ACP discussions was obtained through semi-structured interviews. Results Eighty-six patients’ data indicated that they had engaged in a preferences-for-care process using GWR cards. The top-three card choices by patients was attending to spirituality and religious concerns, preparing for end of life, and maintaining personal wholeness. Conclusion CHWs were able to effectively engage in ACP conversations with patients and GWR cards were a positive way to stimulate discussion of issues previously undiscussed.

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Objectives: Although patients want to participate in discussions and decisions about their end-of-life care, studies show providers frequently fail to invite them to explore advanced care preferences or goals for living. The purpose of this demonstration project was to provide education and coaching to individuals, health providers and organizations across the state of Indiana intended to facilitate these conversations, documenting and honoring individuals' life goals and preferences for care in the final stages of life.Methods: Education and training engaged community members as well as health care providers to: 1) improve participant comfort and facility discussing end-of-life issues; 2) improve knowledge of health care choices, including palliative and hospice care; and 3) prepare all participants to explore and document personal values, life goals and priorities as well as goals of care.Results: Between January 2013 and June 2015, the team educated close to 5,000 participants.Participants' ratings of the quality and perceived usefulness of the events ranged from 4-5 (using 5-point scales; 5 = most effective). Participant comments were overwhelmingly favorable and indicated an intention to put the advance care planning resources, communication skills, knowledge of palliative and hospice care, and personal renewal techniques into practice. Significance of Results:Participant motivation to foster advance care planning, discussions of palliative care, and end-of-life conversations was facilitated by the reframing of these conversations as identifying goals of care and priorities for living well in an important stage of life. Successful strategies included helping providers and patients to adopt a broader meaning for ''sustaining hope" (not for cure, but for engaging in highly valued activities), developing provider communication skills and comfort in initiating potentially difficult discussions, engaging a new community health workforce who developed trusting relationship with patients in home-based services and fostering self-awareness and self-care among palliative care providers.Key words/phrases: Skill development for end-of-life conversations; providers' self-awareness and selfcare surrounding end-of-life care; community health workers' role in end-of-life conversations 3