Building a System-Wide Approach to Support Advance Care Planning Within an Academic Medical Center: Continuity Across...

Area of Science:

• Gerontology and Palliative Care
• Health Services Research
• Medical Informatics

Background:

• Advance care planning (ACP) is crucial for aligning medical care with patient values but faces low completion rates.
• Barriers include fragmented care, inconsistent documentation, and limited electronic health record (EHR) accessibility.
• System-wide healthcare initiatives are necessary to overcome these challenges.

Purpose of the Study:

• To evaluate a health system-wide strategy for enhancing ACP completion and continuity in adult patients.
• The study focused on an academic medical center setting.

Main Methods:

• A retrospective cohort study involved 34,268 patients aged 65 and older.
• A multimodal initiative integrated patient identification, EHR improvements, dedicated social workers, and clinician education across ambulatory, transition of care, and emergency/hospital settings.
• ACP completion was defined by MOLST/Advance Healthcare Directive documents, surrogate identification, or documented goal conversations.

Main Results:

• Fifty-one percent of the cohort completed ACP between February 2021 and January 2024.
• ACP completion likelihood was higher for patients with positive surprise question screens and those with dementia, advanced cancer, or heart failure.
• ACP completion increased significantly during the initiative's implementation periods compared to baseline.

Conclusions:

• A multipronged, system-wide ACP approach across care settings increased completion rates.
• This initiative provides a replicable framework for other academic medical centers seeking to improve advance care planning.