Intervention to increase advanced care planning: a quality improvement project

Abstract

Background: Advanced Care Planning (ACP) is an ongoing process where medical provider(s) combine clinical expertise with patient values to plan for end-of-life. Successful ACP results in goal-concordant care; completion of advanced directives; and ensures satisfaction of Centers for Medicaid and Medicare Services (CMS) quality metrics. Local Problem: The ACP workflow, patient education, and ACP documentation at the project site was not standardized. Average satisfaction for CMS ACP Registry quality metrics, targeting adults 65 years or older, was 63% average for the previous three years, which fell below the 100% benchmark. Methods: The Plan-Do-Study-Act framework was used at a primary care office in the Western United States. A microsystem assessment and ACP quality metrics were reviewed pre-intervention. Descriptive statistical analysis of outcomes was monitored over five weeks. Interventions: Evidence-based interventions included: staff education; standard EMR documentation and template development; new ACP workflow and role delineation; and selection of standard ACP patient education material. Results: Seventy-five percent of staff received ACP education. Seventy-one percent of eligible patients received the ACP packet. The standard EMR template was used with 57% of eligible visits. ACP document completion and plan was prepared for 71% of eligible visits. Conclusion: Although project staff education, workflow, and EMR template improved ACP assessment and delivery by team medical assistants (MA), provider and MA use of the EMR template increased to only 57% as limited time and discussion occurred to necessitate documentation. All interventions were only partially adopted. Full adoption would require further support including the designation of a staff leader.