Enhancing Advance Care Planning in Primary Care: A Three-Year Implementation Study in Nebraska

Despite the benefits of discussing patients' preferences on care decisions, the uptake of advance care planning (ACP) in the U.S. is low. This study aimed to (1) identify barriers to ACP implementation, (2) implement two strategies (onsite ACP coordinator and Lightning Report facilitation-a rapid process improvement involving prompt feedback synthesis and timely action), and (3) track ACP outcomes (reach, implementation, and effectiveness).

This study took place at two primary care sites participating in the Nebraska Geriatric Workforce Enhancement Program from 2020 to 2023. We conducted a multi-stage evaluation mixed-methods study guided by the Practical, Robust Implementation and Sustainability Model (PRISM). Qualitative data from clinic staff interviews and focus groups were collected to identify implementation barriers, develop an optimal workflow, and educate providers and patients (implementation). Quantitative data from electronic medical records (EMR) were collected at baseline and every six months thereafter to assess ACP outcomes, including reach (patient-provider discussion of ACP) and effectiveness (ACP document completion). We mapped barriers to implementation strategies, mechanisms, and ACP outcomes based on PRISM domains.

From 2019 to 2021, ACP outcomes remained consistent: Clinic A (reach: data not available; effectiveness: 20.5%-20.2%) and Clinic B (reach: 2.3%-2.6%; effectiveness: 1.8%-1.9%). After implementing the ACP coordinator and Lightning Report in 2022, moderate-to-high improvements were observed: Clinic A saw a 10-percentage point increase in reach (43.6%-53.6%) and a 2.5 increase in effectiveness (20.2%-22.8%). Clinic B experienced a significant 25.3-percentage point increase in reach (2.6%-27.9%) and a 16.5 increase in effectiveness (1.9%-18.4%). We also updated the clinic workflow to integrate the ACP initiative into standard practice (implementation).

The introduction of an ACP coordinator, along with the Lightning Report approach, may enhance ACP reach, effectiveness, and implementation in primary care settings for older patients.