Advance Care Planning Meets Group Medical Visits: The Feasibility of Promoting Conversations

Abstract

PURPOSE Primary care needs new models to facilitate advance care planning conversations. These conversations focus on preferences regarding serious illness and may involve patients, decision makers, and health care providers. We describe the feasibility of the first primary care-based group visit model focused on advance care planning. METHODSWe conducted a pilot demonstration of an advance care planning group visit in a geriatrics clinic. Patients were aged at least 65 years. Groups of patients met in 2 sessions of 2 hours each facilitated by a geriatrician and a social worker. Activities included considering personal values, discussing advance care planning, choosing surrogate decision-makers, and completing advance directives. We used the RE-AIM framework to evaluate the project. RESULTSTen of 11 clinicians referred patients for participation. Of 80 patients approached, 32 participated in 5 group visit cohorts (a 40% participation rate) and 27 participated in both sessions (an 84% retention rate). Mean age was 79 years; 59% of participants were female and 72% white. Most evaluated the group visit as better than usual clinic visits for discussing advance care planning. Patients reported increases in detailed advance care planning conversations after participating (19% to 41%, P = .02). Qualitative analysis found that older adults were willing to share personal values and challenges related to advance care planning and that they initiated discussions about a broad range of relevant topics.CONCLUSION A group visit to facilitate discussions about advance care planning and increase patient engagement is feasible. This model warrants further evaluation for effectiveness in improving advance care planning outcomes for patients, clinicians, and the system. 2016;14:125-132. doi: 10.1370/afm.1906. Ann Fam Med INTRODUCTIOND espite the benefits of advance care planning for patients, primary care clinicians face barriers to effective counseling on the issue, including their limited time and a lack of clinic-based support. [1][2][3][4] The Dying in America report 5 emphasized the need to integrate advance care planning into clinical care, and the Centers for Medicare and Medicaid Services recently approved reimbursement for counseling on advance care planning. 6 Advance care planning is an ongoing process that involves multiple conversations among individuals, family members, and health care professionals. 1,7 Studies show that many US decedents had not discussed preferences for end-of-life care with someone close to them, completed a living will, or established a durable power of attorney for health care. 8,9 Primary care clinics are uniquely positioned to implement new models that engage patients in advance care planning. 10 The American Academy of Family Physicians recognizes group medical visits (GMVs) as a strategic approach within the patient-centered medical home. 11,12 GMVs, also called shared medical appointments, engage patients in health promotion and disease management. [13][14][15][16][17][18] care, a...

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