Nurse-led intervention increases advanced care planning discussions

A nurse navigator–led intervention called ACPWise that was incorporated into an electronic health record interface increased the frequency of advanced care planning discussions in primary care, data show.

Previous research has shown that advanced care planning (ACP) increases “goal-concordant care” and decreases hospitalizations, in-hospital mortality and health care costs, according to researchers. ACPWise was designed to streamline the process for documenting conversations about ACP to decrease primary care physicians’ workflow, a study author told Healio Primary Care.

“Ideally, advanced care planning should occur routinely as part of primary care, though this is generally not happening despite Medicare now reimbursing health systems for these discussions. Even if advanced care discussions are happening, they are typically not documented in a standard way that can be easily accessed if a patient is hospitalized and incapacitated,” said Jennifer Gabbard, MD, palliative medicine research director at Wake Forest School of Medicine.

The intervention, described in JAMA Internal Medicine, consisted of nurse navigators embedded within a Medicare accountable care organization (ACO) who engaged in ACP discussions with patients. These discussions were chronicled in a centralized location within an integrated EHR interface that the researchers created “to allow primary care professionals to document ACP in a standardized manner.” ACPWise’s mechanisms also severed as a conversation guide and helped ensure the visit was properly billed.

To assess the effectiveness of the intervention, Gabbard and colleagues randomly assigned 759 older patients from eight primary care practices in an approximate 1:1 ratio to ACPWise or a control group. Randomization took place prior to the intervention, and only those chosen for the intervention were approached by researchers.

The researchers wrote that vs. the control group, ACPWise participants had higher rates of ACP documentation (42.2% vs. 3.7%, P < .001); ACP billing codes use (25.3% vs. 1.3%, P < .001), choosing a surrogate decision maker (64% vs. 35%, P < .001) and completing ACP legal forms (24.3% vs. 10%, P < .001).

“Our team was both surprised and very pleased with the findings," Gabbard said. “Prior to conducting this research, of older adults with a high degree of comorbidity and frailty in our ACO, less than 9% of patients had any form of advanced care planning documentation in their medical record. This increase to over 40% was very exciting and promising.”

Many of the in-person ACP discussions were conducted by nurse practitioners and physician assistants, according to Gabbard. Other ACP conversations occurred during the patient’s Medicare annual wellness visit and did not “increase busy primary care physicians’ workload,” she said.

In a related editorial, Vinay Guduguntla, MD, a resident physician at the University of California-San Francisco, and colleagues wrote ACPWise seems “reproducible, scalable and potentially economical.”

“Over time, this approach may help decrease the delivery of low-value end-of-life care,” they added.

References:

• Gabbard J, et al. JAMA Intern Med. 2021;doi:10.1001/jamainternmed.2020.5950.
• Guduguntla V, et al. JAMA Intern Med. 2021; doi:10.1001/jamainternmed.2020.5935.