Improving advance directive conversations in a primary care clinic: a quality improvement intervention

Abstract

Background: Leading American health organizations have emphasized the necessity of promoting end-of-life conversations in health care settings. Yet the rates of these conversations remain woefully low across all settings, including primary care. Advance directives (AD) are documents that relay the degree of medical care desired by a patient. Thus, ADs are a practical and appropriate approach that can be used by primary care providers for initiating end-of-life conversations with their patients. Purpose and Methods: The purpose of this DNP project was to increase the rates of advance directive (AD) conversations between providers and their patients in a primary care setting. The project used provider training instruments that were developed within a scientific framework. These instruments included: 1) a tutorial on the appropriate use of AD related CPT codes, 2) a documentation guide for advance care planning, 3) a conversation guide for discussing ADs with patients, and 4) education on the use of the (AD) form. These instruments were delivered over eight weekly video tutorials and in-person question and answer sessions. Results: The rates of end-of-life conversation at the clinic, as reflected in advance care planning (ACP) documentation and scanned AD forms in EMRs, increased from 12% of patients to 35%. The project also improved patient care and generated revenue for the organization through the utilization of Current Procedural Terminology (CPT) codes related to advanced directive conversations.