Advance care planning for vulnerable older adults within an Accountable Care Organization: study protocol for the IMPACT randomised controlled trial

Abstract

IntroductionPatients with multimorbidity plus additional impairments (eg, mobility limitations, disability, cognitive impairments or frailty) are at the highest risk for poor healthcare outcomes. Advanced care planning (ACP) provides patients and their surrogates the opportunity to discuss their goals, values and priorities for healthcare—particularly in the context of end-of-life care. ACP discussions promote more person-centred care; however, it is currently underused. There is a tremendous need for systematic, scalable approaches to individualised ACP that promotes patient and family engagement. Here we describe the study protocol for a randomised effectiveness trial of a nurse navigator and informatics intervention designed to improve the documentation and quality of ACP discussions.Methods and analysisThis is a randomised, pragmatic, effectiveness trial; patients aged 65 years and older who have multimorbidity plus impairments in either physical function (eg, mobility limitations or disability) or cognition, and/or frailty within an affiliated Accountable Care Organization were eligible. The electronic health record was used to develop an automatic prescreening system for eligible patients (n=765) and participants were randomised in a 1:1 ratio to either the nurse navigator-led ACP pathway or usual care. Our primary outcomes are documentation of ACP discussions within the EHR along with the quality of ACP discussions. Secondary outcomes include a broad range of ACP actions (eg, usage of ACP billing codes, choosing a surrogate decision-maker and advance directive documentation). Outcomes will be measured over 12 months of follow-up.Ethics and disseminationThis study has been approved by the appropriate Institutional Review Boards and is guided by input from patient and clinical advisory boards. The results of this study will inform a scalable solution to ACP discussions throughout our healthcare system and statewide.Trials registration number NCT03609658.

Implementing advance care planning in heart failure: a qualitative study of primary healthcare professionals

“…targeting patients to engage with ACP [19][20][21][22][23][24][25] but not on primary HCPs. The few studies which have examined primary care professionals' experiences with ACP in HF demonstrate concerns about the timing, initiation, conduct and recording of ACP conversations, worries about competency of disease specific communication skills and the lack of resources.…”

Effects of reminiscence therapy in people with dementia: A systematic review and meta‐analysis

“…Sixteen studies, involving 1272 participants, were analysed to explore the effects of reminiscence therapy on depression using the Cornell Scale for Depression in Dementia (CSDD) (Bailey et al, 2017; Faraone, 2008; Haight et al, 2006; Li et al, 2020; Lök et al, 2019; Lopes et al, 2016; Moon & Park, 2020a; Nakamae et al, 2014; O'Shea et al, 2014; Van Bogaert et al, 2013), the Geriatric Depression Scale (GDS) (Bailey et al, 2017; Duru Aşiret & Kapucu, 2016; Faraone, 2008; Hsieh et al, 2010; Justo‐Henriques et al, 2020; Kim, 2020; Lopes et al, 2016; Su et al, 2012; Subramaniam et al, 2014; Van Bogaert et al, 2013), the Neuropsychiatric Inventory (NPI) (Hsieh et al, 2010), and the Multidimensional Observation Scale for Elderly Subjects (Gabbard et al, 2019; Nakamae et al, 2014; Tadaka & Kanagawa, 2007). The random‐effects–weighted SMD was −0.53 (95% CI: −0.70 to −0.36), and significant differences in depression levels were observed between groups ( p < .001).…”

Building a Comprehensive Advance Care Planning Approach in a Community Health System during COVID-19

“…ACP is a vital tool to provide concurrently the care patients want while preserving the finite resources others may need. It is gaining more attention in healthcare systems as an opportunity to deliver goal-concordant care, improve patient quality of life, decrease decisional conflict, and reduce futile medical interventions and costs [17]. The selection of ACP as one of the reform goals of MIPS/APMs has elevated the need to complete ADs and make them available in EMRs.…”

“…Documenting goals of care incentivizes systems to address widespread variation in practice, quality, and cost. As ACOs evolve to risk-bearing models, they seek to improve advanced illness and end of life care while ensuring efficient use of health care services [18,19].…”