Effectiveness of a Nurse-Led Multidisciplinary Intervention vs Usual Care on Advance Care Planning for Vulnerable Older Adults in an Accountable Care Organization

Abstract

Advance care planning (ACP), especially among vulnerable older adults, remains underused in primary care. Additionally, many ACP initiatives fail to integrate directly into the electronic health record (EHR), resulting in infrequent and disorganized documentation.OBJECTIVE To determine whether a nurse navigator-led ACP pathway combined with a health care professional-facing EHR interface improves the occurrence of ACP discussions and their documentation within the EHR. DESIGN, SETTING, AND PARTICIPANTSThis was a randomized effectiveness trial using the Zelen design, in which patients are randomized prior to informed consent, with only those randomized to the intervention subsequently approached to provide informed consent. Randomization began November 1, 2018, and follow-up concluded November 1, 2019. The study population included patients 65 years or older with multimorbidity combined with either cognitive or physical impairments, and/or frailty, assessed from 8 primary care practices in North Carolina. INTERVENTIONS Participants were randomized to either a nurse navigator-led ACP pathway (n = 379) or usual care (n = 380). MAIN OUTCOMES AND MEASURESThe primary outcome was documentation of a new ACP discussion within the EHR. Secondary outcomes included the usage of ACP billing codes, designation of a surrogate decision maker, and ACP legal form documentation. Exploratory outcomes included incident health care use. RESULTS Among 759 randomized patients (mean age 77.7 years, 455 women [59.9%]), the nurse navigator-led ACP pathway resulted in a higher rate of ACP documentation (42.2% vs 3.7%, P < .001) as compared with usual care. The ACP billing codes were used more frequently for patients randomized to the nurse navigator-led ACP pathway (25.3% vs 1.3%, P < .001). Patients randomized to the nurse navigator-led ACP pathway more frequently designated a surrogate decision maker (64% vs 35%, P < .001) and completed ACP legal forms (24.3% vs 10.0%, P < .001). During follow-up, the incidence of emergency department visits and inpatient hospitalizations was similar between the randomized groups (hazard ratio, 1.17; 95% CI, 0.92-1.50). CONCLUSIONS AND RELEVANCEA nurse navigator-led ACP pathway integrated with a health care professional-facing EHR interface increased the frequency of ACP discussions and their documentation. Additional research will be required to evaluate whether increased EHR documentation leads to improvements in goal-concordant care.TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03609658

Advance Care Planning Protocols and Hospitalization Rates in Home Health Value-Based Purchasing

“…McMahan et al 22 conducted a scoping review of ACP outcomes such as quality of care, patient/surrogate/clinician satisfaction with communication, and surrogate satisfaction with patients' care, but did not focus on HH nor include hospitalization specifically. Gabbard et al 23 found incidences of hospitalization were similar between randomized groups in their study of ACP outcomes among patients 65 years or older in a primary care accountable care organization, but this was not specific to HH nor agency ACP protocols. The Arbor Research Collaborative was contracted by CMS to study the impacts of the HHVBP program, which included hospitalization, but their studies in the Third Annual Report of the Evaluation of the Home Health Value-Based Purchasing Model 14 did not examine the role of ACP.…”

What’s Wrong With Advance Care Planning?

“…Additionally, these reviews found no association of ACP with subsequent health care use, including emergency department visits, hospitalizations, and critical care. Subsequently, 5 large multisite randomized clinical trials that enrolled patients with cancer (1117 patients at 23 hospital cancer centers), 3 nursing home residents (12 479 residents from 360 nursing homes), 4 older adults in primary care (759 patients from 8 primary care practices), 5 adults with serious illness (515 patients from 20 outpatient clinics), 6 and patients with heart failure (282 patients from 2 heart failure centers) 7 could not identify meaningful differences in health care use, patient quality of life, or goal-concordant care between those randomly assigned to receive either ACP or usual care.…”

Advance Care Planning Among Elderly Acquired Immunodeficiency Syndrome Patients

“…The ACP discussion requires the cooperation of a multidisciplinary team, in which health care professionals, lawyers, psychologists, social workers, and others all play an important role. This multidisciplinary team should help elderly AIDS patients initiate ACP discussions at the right time, maintain patient autonomy, and improve quality of life and sense of dignity at the end of life 38 . To promote ACP discussions among elderly AIDS patients, the circular support system from educational institutions to social institutions and medical institutions should be established.…”