Increasing Advance Care Planning in a Community Internal Medicine Clinic

Advance care planning (ACP) supports goal-concordant care but remains underused nationally. In resident clinics, limited continuity, short visits, and lack of standardized workflows create barriers to ACP integration. In our Community Internal Medicine resident clinic, ACP discussion was documented in 2.5% of annual physicals, and 19.6% of paneled patients had an advance directive (AD) on file. We aimed to increase ACP documentation from 2.5% to 12.5% within 1 year without increasing perceived resident workflow burden.

We conducted a resident-led quality improvement project using Lean Six Sigma methodology. Three interventions were implemented sequentially: nursing distribution of ACP brochures, an electronic medical record DotPhrase to prompt and document ACP discussions, and targeted patient portal outreach to patients without an AD before annual visits. The primary outcome was documented ACP discussion during annual physicals. Secondary outcomes included AD uploads and ACP consult referrals. The balancing measure was resident-perceived workflow burden. Charts were reviewed over 5-week periods at baseline (n = 118) and after each implementation phase (n = 132, 158, 129).

ACP documentation increased from 2.5% at baseline to 12.2%, 17.1%, and 24.0% across sequential phases (χ2(3) = 24.74, P < 0.0001). Pairwise comparisons versus baseline were significant (all P ≤ 0.005). AD upload rate increased from 1.7 to 6.0 per month, and ACP consult referrals increased from 0.0% to 10.9%. Mean perceived workflow burden decreased from 4.9 to 3.0.

Workflow-embedded interventions improved ACP documentation, AD uploads, and ACP referrals without increasing perceived resident burden.