Nurse-Led Intervention Increases Advance Care Planning Discussions and Documentation

Area of Science:

• Gerontology
• Health Services Research
• Primary Care Medicine

Background:

• Advance care planning (ACP) is crucial for older adults, yet often underutilized.
• Vulnerable older adults face barriers to engaging in ACP discussions.
• Primary care settings offer opportunities to integrate ACP interventions.

Purpose of the Study:

• To evaluate the effectiveness of a nurse navigator-led ACP pathway.
• To assess the integration of this pathway with an electronic health record (EHR) interface.
• To determine the impact on ACP discussions and documentation in vulnerable older adults.

Main Methods:

• Implementation of a nurse navigator-led ACP pathway.
• Integration with a health care professional-facing EHR interface.
• Focus on vulnerable older adult population within a primary care setting.

Main Results:

• Increased frequency of advance care planning discussions.
• Enhanced documentation of advance care planning.
• Successful integration within the primary care workflow.

Conclusions:

• A nurse navigator-led ACP pathway, integrated with EHR, is effective.
• This model enhances ACP for vulnerable older adults in primary care.
• The intervention improves communication and documentation of patient preferences.