Background and Review of Literature: Lack of advance care planning (ACP) leads to unwanted treatments and suffering for patients, along with increased healthcare costs. Certain vulnerable populations are at increased risk for unnecessary suffering, including those with high emergency department (ED) utilization rates and one-year prognoses. Providing ACP education to providers and utilization of the multidisciplinary team has been shown to increase ACP and advance directive (AD) rates in these vulnerable populations within primary care. Purpose: The purpose of this QI project was to increase the percentage of robust ACP conversations and the completion and documentation of ACP/ADs in the electronic medical record (EMR). Methods: The project was implemented at a primary care clinic in a midwestern Michigan community. DNP students attended an informational meeting regarding the organization's EMR-based ACP tool. An educational session regarding robust ACP was held for providers, a decision tree was developed to both guide ACP appointments with a specialist and ensure proper documentation into the EMR, and scripting was created to help guide ACP conversations. Implementation Plan/Procedure: Members of the multidisciplinary team utilized the intervention. Data collection included the percentage of empaneled patients with a durable power of attorney for healthcare (DPOAH) on file, the total number of robust ACP conversations completed, and the number of patients on the population health targeting list were collected. Post-intervention, an online survey was used to assess the provider's attitudes, knowledge, and confidence towards the decision tree. Implications/Conclusion: The intervention produced positive outcomes, which included an increase in completed and documented ACP/AD and provider knowledge regarding ACP.
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