ADVANCED CARE PLANNING 1 Improving Rates of Advanced Care Planning Discussion and Documentation in the Primary Care Setting: A DNP Quality Improvement Study Ogechi S. Aririguzo and Carley A. Olender College of Nursing, Michigan State University NUR 995 Doctor of Nursing Practice Project I Dr. Katherine Dontje Advisor April 30, 2023 ADVANCED CARE PLANNING 2 Table of Contents Abstract …..….....................................................................................................................4 Introduction .........................................................................................................................6 Background/Significance.........................................................................................6 Problem Statement/Clinical Question......................................................................8 Organizational Assessment Analysis of Project Site...............................................8 Purpose of the Project ...........................................................................................11 Quality Improvement Model..................................................................................11 Review of the Literature....................................................................................................12 Cost-Benefit Analysis/Budget ..........................................................................................17 Methods..............................................................................................................................18 Project Site and Population....................................................................................18 Ethical Considerations/Protection of Human Subjects .........................................19 Setting Facilitators and Barriers.............................................................................19 The Intervention and Data Collection Procedure ..................................................20 Timeline.................................................................................................................24 Measurement Instrument(s)/Tools ........................................................................24 Analysis ………………................................................................................................... 25 Sustainability Plan ……………………............................................................................26 Discussion ……………………………………………………………………………….27 Implications for Nursing …………..…………………….................................................28 Conclusion ........................................................................................................................29 References..........................................................................................................................31 ADVANCED CARE PLANNING 3 Appendices.........................................................................................................................36 Appendix A (PRISMA Table)...............................................................................36 Appendix B (Literature Table)...............................................................................37 Appendix C (Fishbone Diagram)...........................................................................48 Appendix D (SWOT Analysis)..............................................................................49 Appendix E (Timeline) .........................................................................................50 Appendix F (Workflow Redesign).........................................................................51 Appendix G (EHR Data Reports)..........................................................................52 Appendix H (Workflow Intervention Effect on CPT II Code Use).......................53 ADVANCED CARE PLANNING 4 Abstract Background: Advance Care Planning (ACP) documents enable patients to receive medical care that aligns with treatment preferences and goals. Discussions regarding ACP in primary care are often inadequate due to patient and provider barriers. The lack of completed ACP documents leads to patient care goals not being addressed and ACP metrics not being met. Major themes in the literature demonstrated that multidisciplinary teams, workflow redesign, staff education, and the use of the Electronic Health Record (EHR) can aid in improving ACP discussion and documentation rates. Purpose: The purpose of this QI project was to improve the existing ACP processes for patients 50 years and older within our designated family medicine clinic by increasing discussion and documentation rates. Methods: The project was implemented in a family medicine clinic in an urban area over a 3 month time period. An ACP focused workflow was implemented defining specific roles and responsibilities for the team members. Pre and post intervention data was collected through the EHR dashboard for patients 50 years and older with and without existing ACP documents. Implementation: During staff meetings, clinic staff and providers were educated about new roles and responsibilities. The Making Choices Michigan Advance Directive form was made available to patients and providers. Staff addressed if a patient had an existing ACP and providers then discussed ACP with the patient. Both were documented in the EHR. The ACP form was given to interested patients to be filled out at home or in the office at a separate appointment with staff. ADVANCED CARE PLANNING 5 Results: Project outcome goal of 30% increase in ACP discussion and documentation was not met. There was a slight increase in the percentage of 5.62%. No statistical change (p=0.16) was noticed when comparing pre-intervention rates of ACP CPT II code use, 1123F (80) and 1124F (41), with post-intervention CPT II code use, 1123F (66) and 1124F (26) after chi square test. ADVANCED CARE PLANNING 6 Improving Rates of Advanced Care Planning Discussion and Documentation in the Primary Care Setting: A DNP Quality Improvement Study Advanced care planning (ACP) is a process applicable to adults of any age to discuss and plan an individual's future health care goals when the individual is still capable of making those decisions (Sudore et al., 2017). In addressing ACP, the goal is that the patient will receive medical care that aligns with their values, goals, preferences, which can aid in decreasing inappropriate health use and spending (Bond et al., 2018). Although ACP is a process that should be considered for all adults, in practice much of the focus is placed on the elderly populations. This may be due to the fact that ACP appears to feel like a more pressing issue with this group. About 60% of elderly adults have at least two or more chronic illnesses putting them at an increased risk of morbidity and mortality (Struck et al., 2017). McMahan et al. (2021) finds that one out of three older adults have documented wishes, while only about 10% to 20% have had a discussion with a provider. This leaves room for much improvement, and primary care providers can play an important role in this process. Many elderly patients are regularly seen in the primary care setting for annual and/or chronic care visits. Additionally, the longitudinal nature of the patient-provider relationship in primary care allows time for trust-building and the opportunity to have evolving advanced care planning conversations. Background ACP involves making plans for the future regarding medical care, including end- of-life care, and relaying this vital information to family members and the medical team. ACP is a continuum that changes with time, related to changes in patients’ values, and ADVANCED CARE PLANNING 7 health status. ACP can include a living will, health care power of attorney, health care proxy, or instructive directions (Yadav et al., 2017). The Patient Self Determination Act (PSDA) of 1991 helped to illuminate the importance of ACP. It required all Medicare funded institutions to make patients aware of their right to state their intentions for medical care should they not be able to make their own decisions (Solis et al., 2018). However, it did not require more to be done to engage or encourage patients in ACP beyond the acknowledgment of their rights and the initial presentation of information. Another significant push for the implementation of ACP was from the Institute of Medicine (IOM), which stressed the importance of ACP as part of a palliative care model (Solis et al., 2018). Bond et al. (2018) found a lack of ACP contributes to increased spending in end-of-life care, while utilization of ACP contributed to a decrease in overall costs by $9,500. Benefits of ACP were found to be improved patient and “surrogate” satisfaction with healthcare communication, as well as a decrease in distress for surrogates and clinicians (McMahon et al., 2021). Therefore, the PSDA highlighted the importance of ACP in healthcare, leading to the Medicare and IOM push to have patients knowledgeable and involved in their own ACP. Despite the evidence of its benefits, the data continues to indicate that we are not utilizing ACP enough. There are numerous barriers that contribute to the low completion rates of advanced directives. Provider dynamics include discomfort about the topic, lack of healthcare support, poor reimbursement rates, time restrictions for office visits, and waiting for patients to bring up the topic (Blackwood et al., 2019). When looking at patients, barriers can include not wanting to burden family or friends, lack of comfort with the topic, poor health literacy, lack of awareness or interest in the topic, culture or ADVANCED CARE PLANNING 8 spiritual traditions, and discrepancies in who initiates the conversation (Poveda-Moral et al., 2021). With barriers recognized and acknowledged, understanding how to overcome the listed barriers becomes pivotal. In 2016, the Centers for Medicare and Medicaid Services created reimbursements codes for ACP visits, creating an incentive for providers to address ACP. The reimbursement demonstrates ACP's value in providing medical care that respects patients' preferences. Palmer et al. (2021) looked at fee-for-service Medicare claims in the outpatient setting during 2017 and found that 2.86% of a total of 33,704,729 Medicare beneficiaries had an ACP claim with a visit. Rates of ACP reimbursement claims from 2016 to 2018 increased from 1.2% to 3.67% in Medicare beneficiaries (Belanger et al., 2019; Palmer et al., 2021). The significantly low counseling rates on ACP, related to the barriers such as time, indicate that better implementation strategies and workflows to improve ACP rates in the primary care setting are needed. With increased involvement and education from providers, patients can take an active role in ensuring their patient's wishes are known. Problem Statement In a family medicine clinical setting, would implementing an ACP workflow utilizing evidence-based practices for those 50 years and older, compared to the usual routine care, encourage increased ACP discussion with patients and subsequent documentation in the electronic medical record. Organizational Assessment Analysis A strengths, weakness, opportunities, and threats (SWOT) gap analysis was used to assess the project site for potential strengths and challenges. The SWOT analysis was ADVANCED CARE PLANNING 9 introduced in the 1960s by Albert Humphrey to evaluate internal and external elements of organizations (Teoli et al., 2021). The assessment allows for both individual and organizational utility with a focus on organizational utility for this project. Below we will examine each of the four sections of the SWOT for this project (Appendix D). Strengths The organization had numerous current strengths to support improved rates of ACP discussion and documentation. It had been an idea driven by our community liaison, who, as of this paper’s writing, serves as the quality director for the parent organization. They utilized regular healthcare data reports that allowed providers to see what was needed to meet benchmarks and created an end of the year recap to demonstrate the revenue captured in incentive money. Improving current clinic practices regarding ACP discussion and documentation rates was designated to be one of the quality goals for the fiscal year. Additionally, the related internal medicine clinic had piloted this work on improving ACP discussion and documentation rates for the last two years. Their EHR system, Athena, could create dashboards to track discussion and documentation rates, with assistance from the IT department. Another strength included the long-term relationships providers create with patients in family medicine, which could help providers guide patients in deciding to complete planning due to their knowledge of the patient and the trust in the existing relationship. Lastly, some providers that work at the family medicine clinic were also faculty at the MSU College of Nursing and could help with project implementation in a teaching capacity. Those strengths were all thought to be potentially beneficial in ADVANCED CARE PLANNING 10 implementing processes to improve ACP discussion and documentation rates. Weaknesses Many weaknesses existed that could potentially have impacted rates of ACP discussion and documentation. Their lack of ACP workflow, or a specific way for ACP discussion to be documented was the most significant weakness noted. This lack of clear documentation seemed harmful for the clinic’s ability to create potential reimbursement through billing codes. With no existing EHR built-in documentation method, tracking abilities for when patients receive these services were limited. Opportunities There were many opportunities present at the project site that related to improvement of ACP discussion and documentation rates. Having an established workflow designating staff responsibilities could be helpful in encouraging increased ACP discussion. In addition, the ACP billing codes could aid in documentation, leading to clinic and provider reimbursement. With increased discussion occurring yearly at annual patient examinations, improved patient knowledge on the topic could occur. Also, with the increased ACP discussions would come improved provider comfortability with the topic. Utilization of the plans highlighted in the methods section could lead to creating these opportunities to exist in the workflow. Threats Many threats exist that could have impacted the success of improved rates of ACP documentation and discussion. Threats included the increased visit time required for providers and the increased workload of all clinic staff involved. The increased workload would include assessing existing ACP paperwork, reviewing paperwork, bringing up ADVANCED CARE PLANNING 11 questions surrounding ACP, and explaining topics and options. Specific requirements exist when utilizing ACP billing codes, and some insurances do not cover this which could be a financial barrier for patients. Additionally, short staffing could affect the need for additional staff members to aid in project implementation success. Lastly, staff dissatisfaction with new responsibilities and changes in the workflow could affect the likelihood of completing tasks or result in the creation of workarounds. Purpose of Project The aim of this project was to implement a DNP student led quality improvement proposal that helped improve the existing ACP process for a population of patients 50 years of age or older within our designated primary care clinic. It involved a review of the current literature regarding ACP in the primary care setting and analyzed this research to determine evidence based practices to be considered for enactment. We then worked with the community liaison from our primary care clinic to review plans for an update to the current workflow in order to increase ACP discussions and the documentation of these discussions within the EHR. The project idea was led by the primary first program the clinic is utilizing to meet quality metrics. Quality Improvement Model We chose the Institute for Healthcare Improvement (IHI) Model for improvement for implementation based on our literature review. We attempted to accomplish an increase in ACP measures in a primary care setting and the intervention focused on increasing efficiency in the clinic’s ACP workflow in order to obtain the desired increase. We were able to determine if our intervention led to an improvement based on qualitative and quantitative data reports from the EHR. The Plan-Do-Study-Act (PDSA) cycle was ADVANCED CARE PLANNING 12 attempted to test changes made for improvement. Review Of Literature Search Methods Mesh searches on PubMed and CINAHL were used. Search terms included advance care planning, end of life planning, advance directive, primary care, family medicine, general practice, electronic medical record, EHR, EMR, and documentation. A total of 179 studies were found, 136 studies were screened after duplicates were removed. Inclusion criteria included articles within the last five years, outpatient setting, English language, patients 50 years or older, full text, and peer reviewed. Exclusion criteria included not related to PICO, wrong indication, wrong intervention, wrong setting, wrong patient population, wrong study design, data outside of desired parameters, low level of evidence, and wrong outcomes. A PRISMA table is present in Appendix A, and a literature table for the eleven extracted studies can be found in appendix B. There are several study designs with various levels of evidence in this literature review. One systematic review and three randomized controlled trials were assessed for quality using the Cochrane risk of bias tool. The remaining extracted studies are as follows: three non-randomized control trials, one quality improvement study, one pragmatic trial, one pilot study, one longitudinal study, and one quality improvement study. Use of Multidisciplinary Teams The use of multidisciplinary teams within practices was present among numerous studies with data to support the use to improve ACP documentation rates. The numerous studies demonstrated the crucial roles for nurses, medical assistants, social workers, and ADVANCED CARE PLANNING 13 PCPs in ACP discussion and documentation rates. Utilization of nurse pre-visit was a commonality to ensure basic questions regarding ACP were addressed (Bose-Brill et al., 2018; Gabbard et al., 2021; Henage et al., 2021). The use of the nurse was to bring ACP ideas to initiate conversation discussion before meeting with the PCP. Front desk staff and medical assistants were also utilized to remind patients about care preferences and remind patients that the provider is interested in care preferences (Bose-Brill et al., 2018; Henage et al., 2021; Marino et al., 2021; Wickersham et al., 2022). These further instilled the importance of ACP in the office visit and to ensure addressment at the visit. In use of all these multidisciplinary teams, the physician or provider is also involved in every study. The provider was there to provide more detailed information on ACP and go off the previous information that was received by the clinical staff. Workflow Redesign The use of the multidisciplinary team leads to workflow redesign, with most studies installing pre-visit screenings to ensure care gaps are met at upcoming visits. The workflow redesign eliminated the usual care of ACP only being discussed by the provider within the office visit. Pre-visit screenings, such as telephone calls or questionnaires, were utilized before the patient's visit and typically did not involve the PCP. This creates a more comprehensive process for ACP discussion, allowing the PCP to go more in-depth on specific topics during the actual office visit (Bose-Brill et al., 2018, Gabbard et al., 2021; Henage et al., 2021; Marino et al., 2021; Wickerman et al., 2022). The implementation of the multidisciplinary team leads to workflow redesign with EHR maximization to ensure care preferences and more in-depth conversations can occur when the patient is one on one with the provider (Bose-Brill et al., 2018; Gabbard et al., ADVANCED CARE PLANNING 14 2021; Henage et al., 2021; Lum et al., 2020). In addition, the multidisciplinary teams initiate ACP discussions to improve the rates and outcomes of ACP provider discussions and documentation. Technology Use with ACP Most of the studies reviewed focused on utilizing the EHR to promote increased ACP documentation rates. These improved ACP rates were associated with pre-screening information sent via the EHR or improved documentation for clinic staff. Most of the control groups, termed ‘usual care,’ utilized mailed documents. Bose-Brill et al. (2018) found that ACP documentation rates in the EHR increased by 27.0% compared to 0.7% with mailed documents. Reidy et al. (2017) found that internet-based ACP outcomes for completed ACPs of registered participants increased by 85%. The use of technology improves access to ACP and can result in quicker and more updated care wishes. The downside of this current trend is that using EHR technology such as MyChart messages can be a barrier for patients who lack exposure or experience with technology. However, as the data shows, mailed documents did not impact ACP rates as much as when EHR utilization occurred. Staff Training Utilization of staff training among the studies demonstrated an increase in staff confidence and improvement in ACP communication with patients. Small group orientations or education sessions were largely utilized for staff training, but while Marino et al. (2021) utilized a DNP ACP educator, most other studies involved communication training programs utilizing video and/or patient interaction simulation (Reidy et al., 2017; Rose et al., 2019; Volandes et al., 2022). Involvement of both ADVANCED CARE PLANNING 15 providers and support staff in education pertaining to roles and responsibilities was consistent across all studies (Marino et al., 2021; Reidy et al., 2017; Rose et al., 2019; Volandes et al., 2022). Implementation of ACP practices by providers using the most effective method, rather than staff education regarding discussion, was the focus of one study in which multiple providers voiced already being comfortable with the concept of having ACP conversations (Wickersham et al., 2019). Literature Gaps Many studies addressed current gaps noticed in the ACP literature. For instance, improved ACP rates were found to be associated with pre-screening information sent via the EHR versus when documents were mailed (Halpert et al., 2022; Lum et al., 2020). This affects the population who lack experience with technology, as mailed documents did not improve rates and the EHR rates greatly improved with intervention. Several of our studies mentioned the limitations involved with the length of study, with our longest intervention period being 1 year (Gabbard et al., 2021; Volandes et al., 2022). Longer follower up would be important to better understand the full impact of these interventions and see how long their effects on discussion and documentation rates may last (Volandes et al., 2022). Additionally, the lack of information on the existent coordination of ACP documentation and patient preferences being followed in end of life care rates is significant as well (Rose et al, 2019). Some of this ACP research may still be in “infancy.” Summary of Findings Our proposed intervention was guided by the common themes found in the ADVANCED CARE PLANNING 16 review of ACP literature. ACP conversation initiation and discussion was largely focused on an elderly primary care population aged 50 years and older. Education and training of providers and staff was often considered, and redesigning current workflow practices to involve all members of the team for improved efficiency and impact has been demonstrated to be important. Finally, the implementation of the EHR as a method to document and track these discussions and preferences, with reminder alerts or clinical decision support as an added aid, has also been strongly indicated (Bose-Brill et al., 2018; Lum et al., 2020; Reidy et al., 2017; Volandes et al., 2022). A fishbone diagram was utilized for gap analysis for ACP discussion and documentation rates, see Appendix C. Six main categories were examined including methods, environment, equipment/technology, materials, providers/staff, and patients for the project site. For methods, lack of written policies, poor familiarity with the EHR and lack of specific location for documentation can be found as barriers to the primary outcome. For the environment, lack of experience surrounding ACP, poor work culture, unsupportive environment, and high stress can contribute to outcomes. Equipment and technology can have a large impact on outcomes as most health systems are now utilizing EHR for data and process improvements; gaps found include need for updated EHR/ a reminder system, places for specific documentation to occur, and tracking abilities to audit data. Access to materials can also contribute to improved ACP rates such as lack of ACP teaching materials, low supply of working computers for staff, easy to read and follow ACP forms/electronic documentation. Barriers to ACP outcomes for providers can include lack of time, low priority in comparison to multi chronic medical conditions, inadequate training, and comfort level with the topic. For patients similar and different ADVANCED CARE PLANNING 17 barriers can be found such as lack of knowledge about ACP, stigma that the provider should initiate conversation, or lack of interest, and differing cultural beliefs. Goals, Objectives and Expected Outcomes The desired outcome, as outlined by our organizational partners, was an increase in the rate of ACP discussions and documentation within the EHR with patients 50 years of age and older. In order to evaluate this outcome, we used data derived from the EHR as it is processed by the IT team on a monthly basis, so that we could assess progression of the intervention. We considered the following smart goal for further clarification of this outcome, so that our criteria for goal completion could be easily understood. Our project goal was to have a 30% compliance rate in ACP discussion documentation for patients 50 years and old in the primary care clinic by the end of implementation period in December of 2022. This would help support the clinic’s desired fiscal goal, based on the Centers for Medicare & Medicaid Services’ (CMS) primary care first program, of having 70% of the patient population have a CPT II code (1123F/1124F) or CPT code ( 99497) added to an encounter in the year 2022. Pre-intervention EHR data from the clinic’s IT department showed baseline ACP rates to be quite low due to the clinic’s current lack of ACP focus (Appendix G) . There was no official procedure for addressing or documenting ACP in the clinic, which prevented achievement of the primary care first program metrics the clinic was striving to reach. Cost-Benefit Analysis After discussion with an organizational liaison, a cost-benefit analysis was created for the proposed project. Both implementation and possible maintenance of this intervention is expected to result in minimal additional expense to the practice. Expected direct expenses, such as the cost of the ink and paper needed to print out the Making ADVANCED CARE PLANNING 18 Choices Michigan Advance Directive form and training materials, was considered to be easily absorbed within the current office budget. For salaried staff, time spent helping patients complete ACP paperwork was deemed minimal and thought to be covered within their current contracts. For staff members that worked hourly–such as the clinic’s medical assistants, registered nurses, and IT technicians–additional time spent for preparation of ACP forms, patient ACP questioning, and/or data report creation was not believed to result in a considerable change in current work time. In comparison, the opportunities for increased revenue due to this intervention were thought to possibly provide good support for its implementation. Direct benefits from having this updated workflow were determined to include not only the increased billing from improved rates of ACP services, but also a possible eligibility for additional incentives from the CMS Primary Care First program if these metrics are attained. An indirect benefit of the project implementation was thought to be a possible improvement in patient and family satisfaction with the practice due to an increased focus in this area of healthcare. Methods This was an evidenced based quality improvement project aimed at improving ACP discussion and documentation rates. We looked at the implementation of an ACP focused workflow within the clinic detailing specific roles and responsibilities for team members and its effect on improving the aforementioned ACP metrics. Pre and post intervention data was collected through the created EHR dashboard for patients 50 years and older with no prior ACP recorded in order to analyze its effect. Project Site and Population ADVANCED CARE PLANNING 19 The project site serves as a primary care facility providing care across the lifespan for members of the tri-county region. The scope of practice of the project site includes diagnosing and treating acute and chronic conditions, preventative care and screening, wellness exams, health risk assessments, immunizations, and counseling on healthy lifestyles for all ages. There are 4,103 patients, 50 years and older, who were seen in the clinic over the last 36 months. The participants in the project implementation include front desk staff, nurses, medical assistants, case manager, nurse practitioners, and physicians. Key stakeholders include patients, clinic staff, health systems, insurance companies, health system policy creators and the government. Participants' education varies from GED, masters, and doctoral degrees with higher degrees having a focus in the medical fields, with participants being the current staff and providers. No recruitment strategies are utilized as participants are the staff and providers in the clinic. Ethical Considerations/Protection of Human Rights Michigan State University Internal Review Board (IRB) approval was obtained before the beginning of project implementation. The official IRB Determination Form was submitted and approved August 30, 2022 . No identifiable patient information, physical, social, psychological, legal, or economic information was collected. HIPAA remained protected, with the project team having access to only aggregated data. This data was collected by staff at MSU Healthcare Inc and only aggregate data was shared with the DNP leads. It was determined that the project resulted in minimal to no risk on staff and providers and that it produced the potential to provide a benefit due to improved understanding of advanced care options from ACP discussion. Setting Facilitators and Barriers ADVANCED CARE PLANNING 20 Our community liaison functions as the quality director at the project site. They work alongside IT and communicate with clinic staff as needed. A SWOT analysis discusses resources, constraints, facilitators, and barriers that were thought to influence the implementation of this project, see Appendix D. In order to overcome the barriers mentioned in our SWOT analysis the authors first discussed a plan with our community liaison to have IT create a user-friendly dashboard for staff to document ACP discussions and documentation rates. Secondly, the plan to best track information (through an ACP dashboard or usage of billing codes) was further clarified. Thirdly, our community liaison noted the ability to use her resources at the internal medicine clinic if unforeseen barriers arose and further guidance was needed. Lastly, every four weeks, we sought to communicate with the nurse manager and or the community liaison to address how the implementation was progressing. Pulled data regarding ACP discussion and documentation rates was used to assess how the monthly success of project implementation was going. We then attempted to alter implementation as needed. The Intervention and Data Collection Procedure: The Plan-Do-Study-Act (PDSA) model is central to quality improvement methods and was chosen to guide the implementation of the project. The PDSA model assesses how interventions work and allows adjustments to be made to improve the desired outcome (Reed et al., 2016). It can be done in numerous cycles to assess outcomes. Our aim was to go through the PDSA cycle as needed and see a 30% compliance rate in terms of ACP discussions taking place with patients 50 years and older in the family medicine clinic by the project’s termination. ADVANCED CARE PLANNING 21 Plan The change tested with the PDSA cycle was to improve ACP discussion and documentation rates with a more efficient ACP workflow, with the aim to have 30% of the patients 50 years and older having ACP discussion and documentation over the project period. We predicted that ACP discussion and documentation rates would increase with a specific workflow design and specific places and ways to document these discussions. While developing the intervention, the authors met with community liaison, the quality director at the project site, throughout several Zoom meeting sessions to better understand the facility's needs related to their ACP metric goals. We introduced the plan at the monthly zoom meeting with clinic staff in September, reviewing the workflow changes and QI implementation. Discussion at the meeting focused on the practice's current ACP process and the plan for implementing the update to the current policy. During this meeting, we shared our findings from the literature review. This phase also included identifying clinic and literature barriers to achieving this outcome. The project site utilized ACP facilitator certification through Respecting Choices for their certified staff, previously the Care Manager. There was a job opening for a new social worker, but a candidate had yet to be selected. Once done, however, the goal was for them to complete the office ACP facilitator certification. However, clinic providers were educated regarding the use of Making Choices Michigan ACP form. The medical assistants were provided with basic education about ACP in orientation and documentation procedure at orientation; staff and provider education occurred via a video meeting. Involvement with multidisciplinary teams was a common theme found in the literature review. Thus, utilization with incorporating multiple ADVANCED CARE PLANNING 22 disciplines can be integral to improving the outcomes. Do We provided staff and provider education about the updates to current ACP workflow practices with a clear delineation of new roles and responsibilities through a video meeting in September. We made multiple attempts to ensure that staff had access to and reviewed the ACP forms available at the clinic. The Making Choices Michigan Advance Directive form was made available to patients and providers at the clinic. The focus was for patients 50 years and older to have the ACP discussion at annual visits. Clinic staff, nurses/medical assistants, were instructed to ask patients if they had an existing ACP document on file or if they had ever had one. From there, the medical assistant was to document whether the patient had or did not have ACP in the chart under social history and leave a comment with the data ACP discussion occurred. During the office visit, the provider would either review the existing form or explain the purpose of ACP, providing the Making Choices Michigan form. Patients could complete the form at home and bring it back to be copied into the EHR or they could schedule an additional appointment with ACP certified staff to complete the form. During the office visit, the clinic staff, medical assistant, would document in the EHR that ACP was discussed and add the coinciding CPT II information, which was used as a quality metric. Documentation changes include documentation of ACP discussion in the social history section in the EHR.. The clinic’s EHR has a social history tab where an advanced directive section can be found within which medical assistants and providers can check either yes or no regarding the patient having an advanced directive in place. Next to the yes or no box, ADVANCED CARE PLANNING 23 there is a comment box where ACP discussion with date can be inputted. Additionally, providers were responsible for going to the billing tab and documenting the CPT II codes, 1123F or 1124F, which are utilized for quality metric tracking. To examine changes made, a pre-intervention audit of patients 50 years and older with and without ACP discussion or documentation on file occurred to establish a baseline. The pre-intervention data report from June 25, 2022, to September 25, 2022, indicated that with patients 50 years and older, the 1123F CPT II code was used 80 times and the 1124F CPT II code was used 41 times, see appendix H. The 1123F CPT II code indicates advanced care planning discussion, while the 1124F code indicates advanced care planning discussion refusal. During the 12-week implementation phase, chart audits took place every four weeks. Study We compared the pre-project data report with subsequent monthly data reports to assess intervention effects. For our goals to be met, the data would need to indicate that the rates of ACP discussion and documentation in the EHR were increasing from the baseline. If the results indicated that our expected outcome threshold, (a rate of 30%) was not being met, we needed to further assess for barriers or failures in our process. During the project we had two opportunities to study the data to gain knowledge as to the effectiveness of our workflow. When unanticipated concerns or more efficient pathways were identified, they attempted to learn about these aspects and create more effective changes to the process. We receive a final data report at the termination of our study. Act We sought to make changes to the intervention based on what we learned from ADVANCED CARE PLANNING 24 each monthly data report and from the nurse manager. We created a workflow redesign for staff to ease this process (see appendix F). The information from our surveys allowed us to include the staff as key stakeholders in the revising process. We hoped to be able to meet each month with our community liaison to discuss the reports. We also planned to reach out to the clinic’s two staff members with extensive experience in workflow creation–their care manager and a nurse working at the internal medicine clinic–if called for. During this phase of the PDSA cycle we would consider the need to adapt, adopt, or abandon our current practices. If the reports indicated that we were meeting our goals, then we would consider adopting the workflow proposed in the intervention. If the reports demonstrated that rates were increasing, but not yet meeting our goals, then we would consider ways to adapt our workflow to encourage improvement in our outcomes. Staff reminders on updated workflow changes, or re-education concerning roles and responsibilities were to be considered as needed. If the reports indicated that our rates were not changing or decreasing, then while we would consider ways to adapt during the study implementation, we would ultimately also need to consider abandoning the intervention upon the study’s termination. Timeline The proposal timeline began in September 2022 following IRB approval and scheduled to end in April of 2023 with dissemination. Detailed projected plan by month can be found in Appendix E. Measurement Instrument EHR data was used in this project. Pre-project data was acquired from IT, from patients 50 years and older with and without ACP discussion and documentation. This ADVANCED CARE PLANNING 25 data provided information on where the clinic ACP discussion and documentation rates were at baseline and aided in demonstrating to what effect this quality improvement project may have impacted those rates over the implementation phase. The EHR data was pulled by a member of the IT team, every 4 weeks, for patients 50 years and older to establish the rates for the patients with ACP discussion and documentation in the EHR. The data was shared by the IT member to our community liaison, who then shared the data with us.. Analysis Results Our desired outcome of having a 30% compliance rate in ACP discussion documentation for patients 50 years and older in the clinic was not met, as only a slight increase in the compliance rate post-intervention was noted when utilizing a proportion table. The pre intervention data proportion was 0.66 and the post intervention proportion was 0.72, demonstrating a 5.62% increase in ACP discussion documentation during the 12 week implementation stage. The data analysis in appendix H encapsulates aggregated data reports from the clinic’s EHR, prior to the start of the intervention. A contingency table chi square test was performed via an online calculator to examine the statistical findings between the data collected during the period before our intervention was enacted and the data following implementation of our intervention (Chi-Square calculator, n.d.). The result of p-value (0.38) > 0.05 indicates that a lack of statistical significance was found. Our intervention, an update to the workflow and staff education on this new process, did not result in a statistically significant difference in use of the CPT II codes chosen to track ACP as a quality measure. ADVANCED CARE PLANNING 26 Sustainability Plan The sustainability plan for this project requires addressing barriers that became present in our last month of the intervention and data collection. In order to ensure the ACP discussion and documentation rates continue to be improved numerous additions would be vital for long term success. The addition of a case manager or social worker to work on assisting patients in completing ACP documents, as well as following up with patients regarding these documents would be crucial in this clinic. As part of the post- intervention reflection, it was communicated the clinic is still looking for a social worker candidate. The hope is to have this social worker available as a resource for the clinic's medical assistants in the ACP process. The clinic is also still in search of a care manager to act as a lead for the new process. Also, understanding how to decrease the staff resistance would aid in better long term results. More frequent check in with staff and presenting the monthly data could help demonstrate the difference the staff is making. In addition, stressing the importance of these metrics to all staff during training and especially to new staff members during onboarding could help this new intervention thrive and progress. An encounter was also set up in the EHR to automatically populate all necessary ACP information for patients 65 years and up, so that the medical assistants don’t have to fill in any paperwork. The clinic is very interested in continuing with this intervention, as its ACP goals align the clinic with the requirements for CMS’s Primary Care First program. Going forward, the hiring of a care manager remains a large priority for sustainability. Additionally, it was surmised that ensuring staff accountability for documentation ADVANCED CARE PLANNING 27 through the use of chart auditing by the quality director, who also served as a community liaison for this study, could also be an option utilized to help address staff resistance. Discussion Although discussing ACP with patients can serve to help providers have a better understanding of their patients' end of life wishes and care goals, the data shows that the rates of ACP counseling remain low. Our study results reflected the current norm and further showed that this can be a complex issue to address. During the evaluation period, a post-intervention reflection with the clinic's community liaison determined several barriers to have played a role in its inability to realize its goal. It was ascertained that a significant issue had been that the clinic lacked a current social worker and/or care manager to serve as a prominent coordinator for the process. An initial staff meeting with the DNP students introducing the project to providers highlighted a difference in opinion amongst colleagues towards the issue that a primary process head may have been able to help navigate better. Other issues of effective success include staffing shortages, inexperienced staff due to turnover, and the staff’s lack of comfort with addressing ACP as a topic. It is likely that the staff resistance and turnover could have resulted from large changes taking place at the clinic such as the nurse practitioners separating into a new clinical space, three different colleges within the university opinions on the intervention, and staff already being overwhelmed with all required documentation. New staff do receive onboarding regarding this intervention with access to the created algorithm, however, the step is still often ignored. The sensitivity of the topic could be further improved with staff training on how to address ADVANCED CARE PLANNING 28 this topic. The role of the social worker/case manager could really help with completion of the ACP forms and further education about the form. Limitations Primary limitations for this study include the inability for the DNP leads to properly conduct adequate PDSA cycling during the implementation phase due to poor communication with several key stakeholders and limited ability to control the parameters of the aggregate data. It was difficult to maintain the necessary level of communication and involvement with staff leadership as numerous attempts made by the DNP leads were often ignored or forgotten. The post-intervention reflection revealed that current staff turnover and shortages had placed a strain on the aforementioned leadership. This had made it difficult for them to keep up with certain goals established during initial and ongoing key stakeholder meetings. Parameters for the aggregate data were discussed via virtual meetings and through email communication, however the DNP leads were not able to communicate directly with the IT team providing the data reports and many requests were needed to get the reports utilized for this paper. Information regarding the number of visits that occurred for the population of interest during the study’s implementation in total, as well the number of visits in which ACP was not addressed, could help create more context for the data. Additionally, pre-and post-intervention surveying regarding the staff’s perception of the intervention and its effect on the desired study goals could have provided qualitative data to help strengthen understanding of the study’s strengths and weaknesses. Implications for Nursing Practice ADVANCED CARE PLANNING 29 The review of the literature surrounding ACP in the primary care setting revealed that increased ACP discussion and documentation rates can be achieved through the use of multi-faceted changes in facility practice (Gabbard et al, 2020; Henage et al, 2021, Marino et al, 2021). Similar to the results of our study, the literature highlights that staff education and organizational support, workflow adoption, and technology advancements in the EHR remain important factors to advancement in this issue (Henage et al.,; Marino et al., 2021). Although our intervention was not found to be statistically significant, subsequent studies may find the limitations detailed in our study helpful if attempting an implementation with comparable goals. Nurse practitioners and other providers can extrapolate that this is an issue in which there is still much work to be done. It not only entails buy-in from the key stakeholders in the clinic such as providers, staff, and management but also continued efforts to ensure that all players understand their role, feel motivated in their roles, and have continued support and encouragement throughout the change process. Additionally qualitative data may have better revealed areas of clinical significance by providing increased insight into staff perceptions related to multiple areas such as the newly created workflow, changes in responsibilities, and behavior adjustments that had or had not been made in response to these changes. The pilot nature of this study does serve as a springboard for further improvement for the site in this regard. Conclusion One out of three older adults have documented ACP wishes, and only about 10 to 20% have even discussed them with their provider (McMahan et al., 2021). This ADVANCED CARE PLANNING 30 demonstrates the need for the topic to be addressed in the primary care setting (McMahan et al., 2021). ACP discussions enable adults of any age to plan future health goals and wishes while the individual is still capable of making those decisions. Having these discussions also equips health care professionals with the knowledge needed to provide treatment consistent with patient wishes and decrease inappropriate healthcare use, thus also decreasing healthcare spending (Bond et al., 2018). A combination of workflow redesign, use of multidisciplinary teams, staff education regarding team role and responsibility changes, and adaptation of the EHR was used in this study to help improve ACP. However, clinic staff turnover and strong staff resistance to change, along with a lack of continued effective communication with clinic leadership and key stakeholders were all found to be significant barriers to outcome progress. The significance of continued organizational support was found to be key for successful implementation. There are many potential avenues for further research regarding the issue of ACP. Some interesting areas to explore include improving understanding of the possible cost benefits of ACP in the primary care setting as well as more examination of what effect ACP may have related to populations outside of our elderly patients. Increased exploration into the amount of congruence between ACP documentation and actual end of life care, or care while incapacitated, should also be considered. This would provide more data regarding the significance of what this proposal hoped to achieve–improved ACP discussions and documentation rates. More information demonstrating what possible gaps may currently exist in this coordination could lead to evidence based improvements being made within this area of healthcare. ADVANCED CARE PLANNING 31 References Belanger, E., Loomer, L., Teno, J. 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Health affairs (Project Hope), 36(7), 1244–1251. https://doi.org/10.1377/hlthaff.2017.0175 ADVANCED CARE PLANNING 36 Appendix A Prisma Table ADVANCED CARE PLANNING 37 Appendix B Literature Table Citation Design/Lev Sample Intervention Measurement: Variables and Findings Strengths/Limitations/ el of Instruments Implications Evidence/ Purpose Bose- Pragmatic Total of 419 Incorporation of an Utilized binomial metrics, such Of the 200 patients sent the Strengths: control an intervention Brill et Trial patients between open-ended ACP as documentation intervention, 39 responded to at group, spot checking during al 50- 93 years with framework (with 4 present/absent, and rigid least one question in the auditing, use ACP quality (2018) Level III active portal questions), sent scoring criteria for quality to framework. Of those who assessment, binomial metrics to between 2 clinical through patients counteract the inability to blind responded 51% added ACP to decreased bias, use of fish exact sites. MyChart account, the study. EHR for the first time and 49% test and mann-whitney test to in addition to already had some form of ACP in analyze and interpret data and its Participants clinical practice Spot checking of reviews EHR. MyChart usage did not significance, and implementation received algorithm. Nurses, occurred to ensure accuracy of increase d/t intervention at either prior to office visit to decrease intervention physicians, and the dataset by 2 trained site. ACP discussion time, (n=200) or other clinical staff members of the team. standard care used the pre visit ACP documentation rates in the Limitations: Baseline ACP (n=219). algorithm to ACP quality was measured EHR increased by 27.0% at the documentation rates differed at promote and ACP using Criteria for Scoring intervention site, compared with a each site. Patients had to have an preference Quality of ACP Documentation 0.7% increase at the control site active MyChart account to be conversations over a during 3 month study period. included in study. Patients had to 3 month period. Fisher Exact test used to assess be 50 years or old to be included whether or not the increase in A Fisher exact test indicated that in study. new documentation was patients exposed to the significant between the 2 sites. intervention were more likely to Implications: Intervention document ACP than those focused on use of EHR portal. Mann-Whitney test was used to receiving usual care, P<.001. The The intervention did not appear analyze the significance in new Mann-Whitney test indicated that to affect the percentage of ACP quality between the 2 ACP documented under our patients who had a scanned sites. intervention was higher in quality, document in their EHR; both P<.001. before and after the intervention. . Only one patient was in 90s, so a Patients aged 50-60 years old had larger sample needed to continue the greatest increase in ACP to confer findings. completion rates, with an increase in documentation of 37% in the intervention group and 1.8% in the control group. ADVANCED CARE PLANNING 38 Citation Design/Lev Sample Intervention Measurement: Variables and Findings Strengths/Limitations/ el of Instruments Implications Evidence/ Purpose Fahner Systematic Literature search Evaluating Cochrane Risk of bias tool 4 Themes in phases of ACP Strengths: High level of et al Review through effectiveness of used for RCTs and non-RCTs- conversations were identified: evidence, evaluates (2019) MEDLINE, using ACP by 2 reviewers and the 2 preparation, initiation, characteristics of interventions Level I Embase, conversation guides reviewers performed risk of exploration, and action. The and content of conversation PsycINFO, and to support health bias assessment on included exploratory phase was the main guides, 2 authors screened CINAHL were care professionals in quantitative studies. part of conversation addressing articles, extracted data and searched from ACP conversations. views on illness, living wills, resolved discrepancies via January 1, 1998, Content of conversation guides death, dying, well-being, discussion, risk of bias to February 23, thematically analyzed using treatment preferences and views 2018. NVivo 10 on others involved in decision Limitations: Some studies making. excluded due to reviewers not 82 articles met the able to reach authors regarding inclusion criteria Scripted ACP conversations more specific conversation reporting on 34 increase dyad congruence and guides, no interventions based unique ACP ACP documentation rates. online/workbooks/patient interventions question-prompt list included (conversation Qualitative research showed that guide for ACP participants appreciate the Implications: discussion, importance and benefits of ACP Further high quality research is english, peer conversations, yet perceive them necessary in answering questions reviewed) as difficult and emotional. regarding the process and effectiveness of ACP. It remains unknown whether conversation themes are most beneficial in improving ACP rates. Research evaluating the relation between guided ACP conversations and whether preference care was provided needs to be evaluated. ADVANCED CARE PLANNING 39 Citation Design/Lev Sample Intervention Measurement: Variables and Findings Strengths/Limitations/ el of Instruments Implications Evidence/ Purpose Gabbard RCT Total of 759 Aims to see if a General linear mixed models Nurse navigator–led ACP Strengths: high level of evidence, et al randomized nurse-navigator led- were used for statistical pathway increased ACP patient automated identification (2021) Level II participants pathway combined analysis. documentation from 3.7% to in EHR, ACP documentation in (mean age 77.7 with healthcare 42.2%, P < .001) as compared EHR to facilitate discussion, and years, 59.9% professional- facing Zelen Design- patients with usual care. use nurse navigators women, 17.1% EHR interface randomized prior to informed African increase ACP consent. ACP billing codes rates increased Limitations: intervention American) discussion and in the intervention group from requiring nurse navigator for documentation rates Nurse navigators trained using 1.3% to 25.3%, P < .001). implementation, depth of survey 146 out of the 294 in the EHR Respecting choices to review information by patients, all eligible patients compared to usual protocol and the ACP wise Patients randomized to the nurse patients from one healthcare randomized to the care. telephone program for pre visit navigator–led ACP pathway more system- impacts nurse navigator planning. frequently designated a surrogate generalizability.1 year study. group consented ACPwise program decision maker (64% compared to Unable to assess long term effect to participate and created in EHR. ACPwise program created for usual care of 35%) and completed on care, medical decisions, or 139 completed the EHR for health professionals ACP legal forms (24.3% cost. intervention. ACPwise telephone for office visits. compared to 10.1% of usual care, program created for P < .001). Patients were nurse navigators Manual review of EHR by 2 Implications: Further research from 8 different independent reviewers blinded needed to assess if increase ACP primary care to the randomized assignment. documentation leads to practices in North improvement following of Carolina, Quality of end-of-life patients wishes in care 65 years or older, communication (QOC)47 affiliated with an survey was used in the accountable care Intervention group to assess organization ACP perspectives. (ACO), seen primary care Quantification of data through: professionals in ACP billing codes (99497, the last 12 99498), documentation of a months, have designated decision maker, evidence of completion and upload of new multimorbidity ACP forms) within the EHR. ADVANCED CARE PLANNING 40 Citation Design/Lev Sample Intervention Measurement: Variables and Findings Strengths/Limitations/ el of Instruments Implications Evidence/ Purpose Halpert Longitudina 426 patients aged Electronic or mailed Variables include age group, In the 3 months after the reminder Strengths: inclusion and et al l 75 years or older messaging to both sex, mailed or electronic had been sent to patients and exclusion criteria, patient (2022) (median age 81 the patient and the papers, completion of ACP providers, new ACP population, large teaching setting Level IV years, 64% provider concerning electronically or scanned in. documentation or billing was women, 92% the absence of found in 28.8% of the patients. Limitations: no factors identified english speaking) documentation of Descriptive statistics were used to help patients and medical over 3 months ACP in the medical to report demographic 75.6% new documentation was providers that will or will not record before an characteristics, health care health care decision maker with respond to an ACP prompt, mail already scheduled utilization, medical history, and new DNR orders placed for reminders may not have been appointment for provider characteristics for the 32.3% of these patients. received, lack of tracking if alert patients 75 years chart review. sent through the mail or and older. The new Medicare billing code electronically, chart review did Data was cleaned for accuracy was filled 10 times (7.8%) not dive into if ACP done at and missing values, if initial visit or subsequent visit, discrepancy it would be short duration, labor intensive for reviewed again. Reminders sent to both patients staff and providers can increase Student’s t-test was used for documentation of ACP during Implications: additional categorical variables and Chi- primary care visits, but rarely interventions combined with square for continuous triggers a full ACP conversation. notices are needed to improve variables. Statistical complete discussions of ACP. significance was set at p < 0.05 and data were analyzed using SAS 9.4. ADVANCED CARE PLANNING 41 Citation Design/Lev Sample Intervention Measurement: Variables and Findings Strengths/Limitations/ el of Instruments Implications Evidence/ Purpose Henage Non- 9,962 patients 65 EMR updates, Use of descriptive statistics for Smaller clinics with fewer Strengths: inclusion and et al randomized years or older workflow redesign, pre and post intervention providers had greater intervention exclusion criteria, variety in (2021) before and with one or more and rates. Those with < 1,000 visits socioeconomic levels, addressing after study chronic conditions multidisciplinary Generalized estimating per year were more than 3 times 3 outcomes, variety in clinic from 13 primary staff education to equations (GEE) were used to as likely to have patients engaged location Level III care clinics in improve rates of examine the odds of ACP in ACP post-intervention. North Carolina. ACP, ACP EMR, discussion and billing, Limitations: Variability among discussion, controlling for within-practice ACP discussions with providers the different independent clinics, documentation of clustering. increased post-intervention, to copays for ACP billing, did not ACP and billing for 52.1% with prior being 24.6%. embed change processes, pre- ACP The Chi-square statistic was This is statistically significant, existing relationships, no used to further examine within- with providers more than 2 times mention of bias practice intervention effects. as likely to have discussions post intervention (OR ¼ 2.2 (95% CI: Implications: Greater evidence Analyses were performed using 1.1, 4.6), p ¼ 0.03) as compared and studies is needed to see the the SAS Statistical Package to pre-intervention. widespread effects on each measurement assessed. Practice Support Services ACP documentation rates in EMR Increasing staff education and (PSS) consultants were utilized increased from 9.9% pre workflow, discussion rates and at all clinics to assess and intervention to 12.6% post ease of use in EMR can improve workflow design. PSS intervention. contribute to increased ACP consultants also engaged in discussion and documentation interprofessional training. Encounters billed for ACP rates. increased from 3.3% pre intervention to 5.2% post intervention, not statistically significant. ADVANCED CARE PLANNING 42 Citation Design/Lev Sample Intervention Measurement: Variables and Findings Strengths/Limitations/ el of Instruments Implications Evidence/ Purpose Lum et RCT 110 participants Use of the Randomization of eligible At 6 months, 71% of ENACT Strengths: high level of evidence, al 60 years or older ENgaging in patients using computerized participants had an advance inclusion and exclusion criteria, (2020) Level II (mean age of 77 Advance Care random number generator directive in the EHR compared use of group visits, use of years old, 60% Planning Talks with 45% of the control group (P ENACT female, and 79% (ENACT) in group ACP documents in EMR < .001). white. visits to improve assessed at baseline, 3 months, Limitations: homogeneous study ACP documentation 6 months, and 12 months after 93% of ENACT participants had population, 20% of patients and readiness. enrollment. decision-maker documentation in randomized to group visit did not the EHR compared with 73% in attend, possibility for selection ENACT includes ACP 4 item Engagement the control group (P < .001). bias. conversation start Survey used to assess ACP kit, Colorado readiness at baseline and 6 ENACT participants trended Implications: Use of the ENACT DPOA form, group months. toward higher readiness to engage program with group and health visits with physician in ACP compared with control at care professional visits have and social worker. Descriptive statistics calculated 6 months (4.56 vs 4.13; P = .16) higher rates of ACP discussion for age, sex, race insurance than receiving mailed ACP Control group- type, relationship status, materials. received mailed education, and whether patient ACP materials was a caregiver. Chi-square tests compared patient characteristics between the intervention and control group ADVANCED CARE PLANNING 43 Citation Design/Lev Sample Intervention Measurement: Variables and Findings Strengths/Limitations/ el of Instruments Implications Evidence/ Purpose Marino Descriptive Multi-clinic DNP led orientation Data was collected through an Across the healthcare center, Strengths - Integrated EMR. et al quality federally qualified educating staff integrated EMR. They assessed conversation documentation rates Standardization of an ACP (2021) improvemen health center in concerning ACP, rates of AD conversation increased by 26% after the process and documentation t study Florida with 11 AD forms, ACP documentation by looking at intervention. site locations. patient interactions, the number of CPT codes Limitations - They were not able Level V and detailing a new billed that indicated the patient This is despite a 27% drop post to look at rates of completion of (n) - not explicitly workflow policy had an AD that was either study that was attributed to return ADs or assess the completeness Evaluation stated. In 2014 the with specific roles. complete (1157F) or not to a 15 min visit time and a of the ADs. Other barriers of a DNP center’s complete (1158F) and decrease in ACP commitment. included limitations on time and led quality population Phase 1 - Nurse comparing it to the total cultural differences regarding improvemen included 6,000 manager overseeing number of patients 50 years or participant beliefs about ACP. t patients 60 or proper role and older seen during the study. intervention older. adherence at Site 1. They also did interviews with Implications - Future such focused on PDSA of process. some participants to learn more initiatives can be made in other increasing Study population: Procedures about how the process was FQHC’s that address ACP for advanced patients 50 years standardized and perceived. older populations. The study directive or older. implemented at Site suggests further research for how documentati 2. this can improve patient & on rates in family satisfaction and retention. the primary Phase 2 - care setting. Procedures/workflo w introduced to the 9 other sites with project champions holding separate education meetings for staff and providers. ADVANCED CARE PLANNING 44 Citation Design/Lev Sample Intervention Measurement: Variables and Findings Strengths/Limitations/ el of Instruments Implications Evidence/ Purpose Reidy et Pilot Study 2 subspecialty Multifaceted: Not extremely clear. Post Internet based ACP outcome: Strengths - Leadership al clinics and a surveys utilized. 85% of registered participants designated for system wide (2017) Level of primary care Internet-based ACP completed ACPs ( patients = 224, model creation/implementation Evidence - practice having a tool that involved Data collection tools were 583 =employees and medical/ (Division of Palliative Care) Unknown high number of at- EMR integration. created to measure outcome nursing students) Diverse populations considered. risk Medicare metrics such as goals of care To assess ACO patients Simulation based discussion importance, patient Provider education: participant Limitations - a significant utilization within the Umass education and small preferences for treatment, post surveys (N = 10 at one technology barrier was found for of an Memorial Medical group training health care proxy month, N = 13 at three months) the older patients within the Internet Center system. across disciplines identification/documentation in indicated increased provider subspecialty clinics and thus the based ACP focused on ACP, EMR, and introduction of the confidence and early starting of Internet based ACP tool was not tool as an Internet site goals of life internet-based ACP tool. ACP conversations with high risk really relevant in this area. aid for Intervention: conversations, and patients. 90-100% satisfaction facilitator (n=807) serious illness Assessment tools were used to with training scenarios. Adoption Medical healthcare setting led ACP. conversations. assess for patient engagement of program by the internal perhaps not as conducive for an Provider barriers (e.g., language medicine residency program now internet tool intervention. Hospital education: (n=27) ACP inclusion in barriers, knowledge readiness, support. leadership the healthcare technology issues). Sustainability of ACP lead was wanted to Clinical system’s employee Employee wellness campaign: not considered early in clinical address Intervention:: wellness campaign 72% of internet based ACP tool interventions. patients/co Multispecialty registers were mmunity lung cancer clinic Clinic workflow employees/students. Implications - Additional members - (n=112) analysis and change supplemental ACP information most at risk to include an ACP Clinic: palliative care specialist and resources needed along with for Posthospitalizatio implementation was able to identify barriers at internet based tools to make ACP rehospitaliz n heart failure team. Palliative care lung cancer clinic – limited time, more realistic for economically ation and clinic - (n=377) specialist to assist access to computers, speaking a and culturally diverse patients. death providers with ACP language other than english, etc. Internet based tool may serve as conversations readiness preparation for families 92% of patients at the heart before discussions with failure clinic were introduced to healthcare providers. an internet based ACP website. . ADVANCED CARE PLANNING 45 Citation Design/Lev Sample Intervention Measurement: Variables and Findings Strengths/Limitations/ el of Instruments Implications Evidence/ Purpose Rose et Nonrandomi Phase 1: 36 Initiation of ACP in Outcomes were measured Phase 1 - 7,200 unique patients Strengths - Intervention al zed control primary care a primary care through EMR analysis. with ACP conversations and potentially generalizable (2019) study practices within a setting using COL, Phase 1 - Initiated ACP EMR documentation. 5392 of unified health care a system-wide conversations and ACP conversations, intervention Limitations - Not a randomized Level III system. community documentation measured practices and 1808, comparison trial. No baseline measurement outpatient model. through “yes” checkboxes in practices. of ACP intervention To assess if The 19 practices practices’ ACP summary. creation/implementation. No the that were part of Phase 1 - Phase 2: Best practice alerts for collection of population Conversatio the Medicare communication Phase 2 - assessed practices five intervention practices and demographics or illness data. ns of a Comprehensive coaching for using BPA measures and the seven comparison practices. Difficult to gauge CPCi model Lifetime Primary Care providers percentage of patients with one Average of 29% of initiated ACP impact on intervention. Limited (COL) Initiative project (VitalTalk), training or more ADs in the chart. conversations resulted in AD practices decided to use BPA intervention (CPCI) served as support staff as completion. Similar AD alert, possibly self-selecting for would have the intervention ACP facilitators Phase 3 - Documented ACP completion rates for intervention intervention change. an effect on group and the using The conversations, measured by a and comparison practices. the number other 17 practices Respecting Choices “yes” checkbox. Implications - Multifaceted ACP of patients served as the Last Steps program, Phase 3: (After the study period): interventions can perhaps be who had comparison ACP nurse liaison 7,589 new ACP conversations. successfully implemented in the ACP group. support, and EMR 123 billed using ACP CPT codes. primary care setting to help discussed updates. increase ACP conversations and with them Phase 2: 12 of the documentation by providers original 36 Phase 2 - Phase 1 and had this practices chose to components and the documented use the BPA alert utilization of a BPA in the EMR alert to help identify as well as patients most what appropriate for ACP percent had focus (fully AD cognitive, 65+ documentati years) on included in the EMR. Phase 3 - Tracking continued after end of study. ADVANCED CARE PLANNING 46 Citation Design/Lev Sample Intervention Measurement: Variables and Findings Strengths/Limitations/ el of Instruments Implications Evidence/ Purpose Volande Pre-post, A New York ACP or Covid EMR analysis for ACP This intervention, implemented Strengths - Health literacy level s et al open-cohort metropolitan area related video discussion, documentation. during the evolving COVID-19 assessed and two language (2022) nonrandomi ambulatory decision aids for Preferences identified using pandemic, was associated with options available. zed network of 22 patients 65 years or human-assisted natural higher rates of ACP controlled clinics. A total of older. language processing (NLP) documentation, especially for Real time monitoring of fidelity trial 14,107 patients communication African American and Hispanic to the intervention via interacted with skills training for patients. technology included in study. Level III clinicians during clinicians. Videos the pre–COVID- available 1-2 weeks Primary outcome: ACP Limitations - Possible Covid-19 Assessed if 19 period, 12 806 before visit. documentation identified in 3587 disproportionate effects, death intervention during wave 1, patients (23.8%) during the rates (particularly for racial s focused on and 15 106 during Video use was intervention period vs. 2525 minorities) may have impacted using video the intervention monitored weekly patients (17.9%) during the pre– documentation results. aids and period. and , and method of COVID-19 period and 1598 communicat dissemination (12.5%) during wave 1. Similar Length of study (6 mo.) ion training Patients 65+ years changed based on results found in sensitivity led to with at least 1 use. analysis. Not randomized, possible increased clinic or telehealth confounders ACP visit during any of Provider ACP and Secondary outcome: All ACP documentati the 3 study Covid documentation areas were greatest Missing race/ethnicity data: 6.3% on, periods. communication during the intervention period. of patients in pre-Covid period, particularly training: 4 hrs, 6.9% wave 1, 7.6% intervention during the Special focus VitalTalk Goals of care - identified for 3506 period. However, were within Covid-19 towards African patients (23.2%) vs. 2383 recommended guidelines for pandemic. American and ACP documentation patients (16.9%) during the pre– hospital race/ethnicity data Hispanic patient elements: COVID-19 period and 1512 evaluation. outcomes discussions about (11.8%) during wave 1. goals of care and Late Spanish language option preferences for Health care proxy - identified for introduction medical care, 2670 patients (17.7%) during vs. palliative care, 1637 patients (11.6%) during the Implications - Generalizable, hospice, and health pre–COVID-19 period and 1024 larger and longer such study care proxy (8.0%) during wave 1. could be beneficial. Subgroup analysis: ACP documentation among racial minorities increased during the intervention vs. the other two periods. ADVANCED CARE PLANNING 47 Citation Design/Lev Sample Intervention Measurement: Variables and Findings Strengths/Limitations/ el of Instruments Implications Evidence/ Purpose Wickers Pair- Six primary care Implementation of Staff meetings and The Five Wishes form was Strengths - Focused on ham et matched practices (n = the Oklahoma patient/clinician interviews for considered easier to read, implementation of ACP, al cluster 246) Advance Directive intervention assessment. understand, and use. It helped effectively relaying patient (2019) randomized (OKAD) or the Five providers have ACP preferences. study Wishes form for NVivo v11 software used to conversations more than the 65+ years eligible, ACP planning record, transcribe, and code OKAD, and better relayed Limitations - A shortened Level II those who interviews with independent patients’ end of life preferences. implementation timeframe and a accepted the form researchers for qualitative small number of study sites. To were considered Progress notes, analysis. Patients were 3.89 times more determine participants. reports, and likely to accept the Five Wishes Some Five Wishes patients and which ACP attachments Quantitative data analysis with form when offered versus the clinicians had previous OKAD form would Retrospective examined to SAS v9.4 instrument, direct OKAD. form exposure prior to serve to be chart abstractions determine AD form analysis method participation. more used to look at completion in 5 yr. ACP conversation barriers: time effective/wi medical records period. Logistic regression utilized to & care process/workflow Implications - Need for various dely utilized from participants model AD form offering and pathways to address over 5 years Staff kept log acceptance. Age and gender implementation barriers. (representative detailing offering controlled for. Teamwork b/t providers and staff and randomly and acceptance of selected). (n=100) forms, specific for each clinic’s workflow. 2 unique identifiers for each patient ADVANCED CARE PLANNING 48 Appendix C Fishbone Diagram Methods Environment Equipment/Technology Lack of written Lack of expertise policies Updated EHR/Reminder support Poor work culture Poor familiarity with EMR EMR documentation use for ACP Not supportive Lack of specific location for documentation High stress Tracking capabilities ACP Discussion & Documentation Lack of teaching Lack of time Lack of knowledge about materials ACP Prioritization of medical conditions Working computers for all staff Not sure if they should members Inadequate training/ initiate/lack of interest unsure of roles & Easily read/understood Comfort level with Not in line with cultural advanced directive forms ACP subject matter beliefs Materials Providers/Staff Patients ADVANCED CARE PLANNING 49 Appendix D SWOT Analysis Strengths Weakness ● Support from clinic staff and ● Lack of ACP prioritization community liaison ● Need for additional staff members ● Guidance from case manager and ● No current workflow in place for RN at internal medicine clinic ACP planning ● EHR capabilities ● Need for updated EHR ● Engaging staff/ team dynamics documentation ● Family medicine clinic- longitudinal relationships ● Providers that also work as faculty members/in a teaching capacity Opportunities Threats ● Increased documentation for ACP ● Increased visit time discussion ● Increased workload ● Increased billing documentation ● Depending on insurance, maybe and monetary kickback charged for CPT billing utilization ● Improved patient outcomes for ● Need for additional staff members current or future needs ● Patients forgetting to return the ● Increased patient knowledge of visit with ACP paperwork ACP options ● Staff dissatisfaction with new ● Increased provider ease with ACP responsibilities discussion facilitation ● Increased ability to cater to elderly population, particularly those with multiple comorbidities ● Family satisfaction ADVANCED CARE PLANNING 50 Appendix E Timeline Month Tasks September IRB Approval Updated ACP Check in with the liaison documentation in EHR and care manager/social worker. Initial project introduction during staff monthly meeting. October Project site Monitor data- pull Check in with staff to implementation initial pre-project data, assess for begins then again every 4 strengths/weakness/compli weeks cations in implementation November Project site Monitor data- pulled Check in with staff to implementation every 4 weeks assess for continues strengths/weakness/ complications in implementation December Project site Monitor and pull final implementation data. —----------------------------- completes January Data analysis begins Data interpretation Establish working begins relationship with statistician February Data analysis Data interpretation Reach out statistician with continues continues any further needs/questions March Interpret outcomes Relay outcomes results Complete final paper to key stakeholders April Dissemination- —------------------------- —----------------------------- proposal presentation ADVANCED CARE PLANNING 51 Appendix F Workflow Redesign ADVANCED CARE PLANNING 52 Appendix G EHR Data Reports Table A1: Pre-intervention - Data Period 6/25/22-9/25/22 50-64 year old 65 and older 1123F 4 76 1124F 17 24 Table A2: Post-Intervention - Initial Data Period 9/26/22-10/24/22 50-64 year old 65 and older 1123F 1 22 1124F 1 13 Table A3: Post-Intervention - Intermediate Data Period 10/25/22-11/21/22 50-64 year old 65 and older 1123F 2 28 1124F 0 8 Table A4: Post-Intervention - Final Data Period 11/22/22-12/19/22 50-64 year old 65 and older 1123F 0 13 1124F 0 4 ADVANCED CARE PLANNING 53 Appendix H Workflow Intervention Effect on CPT II Code Use Pre-Intervention Post- Intervention Marginal Row Totals 1123F 80 (82.94) [0.1] 66 (63.06) [0.14] 146 1124F 41 (38.06) [0.23] 26 (28.94) [0.3] 67 Marginal Column totals 121 92 213 The chi-square statistic = 0.7665 P-value = 0.381294, not significant at p<0.05