ADVANCE CARE PLANNING 1 Charting the Course: Advance Care Planning Conversations with Primary Care Providers During Medicare Wellness Visits Elizabeth E. Smith Edson College of Nursing and Health Innovation, Arizona State University Author’s Note Elizabeth Smith is a registered nurse and third-year DNP-FNP student at Arizona State University. She has no known conflict of interest to disclose. Correspondence should be addressed to Elizabeth E. Smith, Edson College of Nursing and Health Innovation, Arizona State University, Downtown Campus, 550 N. 3rd Street, Phoenix, AZ 85004. Email: eecarlto@asu.edu ADVANCE CARE PLANNING 2 Abstract Background: Advance Care Planning (ACP) conversations are discussions between patients, providers, and loved ones addressing key care decisions in the event of incapacity. Nearly twothirds of US adults have not completed an Advance Directive (AD), yet ACP conversations rarely occur in practice. The objective of this quality improvement project was to implement workflow changes with a reminder system to facilitate ACP conversations during Medicare Wellness Visits (MWV). Method: Social Cognitive Theory describes the complex relationship between variables that can influence an individual’s decision to address ACP. Providers in a primary care office in the Southwestern United States participated in an ACP education session and confidence survey. Patients presenting for the MWV were screened for ACP, and visual reminders were attached outside the exam room for provider review. Aggregate data were used to evaluate provider surveys. Descriptive statistics were used to evaluate patient characteristics and the Chi-square Test of Independence, and Fisher’s test was used to compare the pre-and post-intervention advance directive documentation. Results: Qualitative feedback from the survey indicates reminders and easily accessible resources may help facilitate ACP conversations. Of the 251 MWVs, 21 (8%) had an AD documented, significantly less than the nationally reported rate of 37.7% (p < 0.05, z = -2.39). Conclusions: Healthcare providers face multiple barriers preventing or delaying ACP conversations in practice. System-level changes and provider education can improve the rate of ACP conversations and impact patients’ care at the end of life. Keywords: advance care planning, quality improvement, reminder system ADVANCE CARE PLANNING 3 Acknowledgments A special thank you to my faculty mentor, Dr. Elizabeth Reifsnider; DNP project site champion, Dr. Jacqueline Kasnot; and for the support and love of my husband, Erik, daughter, Raiden, and family. ADVANCE CARE PLANNING 4 Charting the Course: Advance Care Planning Conversations with Primary Care Providers During Medicare Wellness Visits Across the lifespan, quality health care that aligns with the patient's values is paramount to patient satisfaction. Advance directives (ADs) impact individuals at any age who are unable to make their own health care decisions due to an emergency, illness, or end-of-life (EOL). An AD is a legal document that becomes effective when the individual becomes incapacitated and details the type of medical care they would want to receive (National Institute of Aging [NIA], 2018b; Sudore et al., 2017). Planning for the unexpected by completing ADs allows individuals to express their values and wishes concerning EOL care (NIA, 2018a). If necessary, available ADs can help guide the surrogate decision-maker to prioritize the patient's preferences and advocate for these choices (Devnani et al., 2017). Targeted patient education to those who can benefit the most from ADs may increase the completion rate and result in more appropriate medical care that aligns with the patient's wishes. Problem Statement The United States is predicted to have rapid growth in people 65 years of age or older over the next 30 years (Roberts et al., 2018). According to the Centers for Disease Control and Prevention (2018), ADs are an essential part of health management in older adults with one or more chronic conditions. Nevertheless, nearly two-thirds of US adults 18 years of age and older have not completed ADs, a figure that has not changed over the previous six years (Yadav et al., 2017). In addition, comparable rates for AD completion occurred in patients with chronic diseases and healthy adults. The Institute of Medicine (IOM) first addressed the subject of death and dying with a landmark report that promoted improvements in advance care planning (ACP) and EOL care in addition to physician reimbursement for ACP conversations by Medicare (Field ADVANCE CARE PLANNING 5 et al., 1997). A later IOM (2015) report emphasized the need for more ACP conversations with health care providers (HCP) with documentation in electronic health records. A recent consensus statement defined ACP as a way of aiding "adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care” and to “ensure that people receive medical care that is consistent with their values, goals, and preferences during serious and chronic illness" (Sudore et al., 2017, p. 826). Discussions may begin at any time and are continually adjusted based on the patient's current health status (IOM, 2015; Sudore et al., 2017). ACP should prepare the person to make an educated decision regarding medical care goals and may include identifying another trusted individual in making medical decisions. Yadav et al. (2017) suggest that AD policies and interventions should focus on populations with low AD completion rates and a high risk for adverse EOL outcomes. ADs may include a living will, medical durable power of attorney (MDPOA), and other documents such as Do Not Resuscitate orders, and organ and tissue donation documents (NIA, 2018a). Living wills are documents that communicate to HCPs which procedures, or conditions in which procedures, may apply if the person is dying or otherwise unable to communicate their treatment decisions. An MDPOA is a legal document naming a health care proxy; someone trusted to make medical decisions on a person's behalf. If the individual wishes to have specific instructions for other issues not covered by the living will, additional orders and forms may require the provider's completion. Purpose and Rationale As the world faces the novel coronavirus pandemic, patients and providers must become accustomed to a new reality that resources can quickly become scarce, and health conditions can ADVANCE CARE PLANNING 6 dramatically change (Curtis et al., 2020). Before a severe acute illness, ACP discussions regarding care goals should be a high priority, especially for patients with chronic medical conditions. The completion rate for ADs has remained unchanged in recent years, prompting the need for ACP discussions, and increasing patient understanding of ADs at a time when resources are limited (Yadav et al., 2017). Background/Significance Community-Dwelling Adults Overall, ACP conversations can be of great value, prompting the patient to explore their options and discuss these decisions with their HCP and other trusted individuals. According to a recent systematic review, patients 65 years of age or older were significantly more likely to have completed an AD (45.6%) compared to younger adults (31.6%); however, the highest rates of completion were among patients in hospice or palliative care (59.6%) and nursing homes (50.1%) (Yadav et al., 2017). Patients included in another review emphasized that the ACP conversation should happen sooner rather than later, and it is easier to manage when in relatively good health (Zwakman et al., 2018). Furthermore, some patients felt they were not ready to discuss ACP and had some resistance, while most reported having a positive experience. ACP education With an increase in electronic health record (EHR) utilization, secure patient electronic messaging has rapidly increased in utilization. In 2017, almost 91% of Arizona office-based physicians used an EHR (Myrick et al., 2019). Fine et al. (2016) found technology to be a valuable tool to facilitate ACP and AD documentation in EHRs. A recent randomized controlled trial assessed the impact of personalized ACP EHR messages through a secure patient electronic messaging [PEM] system on AD completion in a primary care setting among older adults (Tieu ADVANCE CARE PLANNING 7 et al., 2017). Patients with older age and higher medical complexity had statistically significant increases in AD completion (p < .001 and p = .017, respectively). A personalized approach may improve the experience of ACP, considering the individual's needs and coping styles (Zwakman et al., 2018). Some older adults may be reluctant to use EMRs for AD documentation. In contrast, others are more likely to use an electronic format with easy-to-find features and embedded resources for AD completion (Portz et al., 2020). Portz et al. (2020) utilized ACP portal tools with evidence-based resources, the ability to send messages to the ACP support team and followup, and to complete a legally valid, state-specific electronic MDPOA form. PEMs can be directed to specific, at-risk populations and sent at multiple time points, allowing for a continued conversation as the patient's understanding grows (Tieu et al., 2017). Tieu et al. (2017) utilized a personalized PEM explaining the ACP process with encouragement to complete and a link to an ACP workbook to guide the patient and their loved ones through the process. This intervention is both cost-efficient and potentially sustainable. Furthermore, as patients experience increased ACP engagement levels, there is an associated increase in positive perceptions of EOL experiences (Levoy et al., 2020). Usual Care Providers often view ACP discussions as a vital tool for EOL conversations that can provide a multitude of benefits to the patients and their relatives. However, the frequency of ACP conversations in practice remains low and may be attributed to patient barriers such as fear of death, planning, and concern of burdening their loved ones (Zwakman et al., 2018). Most ACP interventions have been informational, and focused on increasing AD completion rates and improving proxy-decision making; however, there is a lack of high-quality research that ADVANCE CARE PLANNING evaluated ACP interventions (Johnson et al., 2018; Weathers et al., 2016). Stagnant AD completion rates may be associated with HCP concerns that ADs have not been used to their potential and result in decreased provider promotion of use (Yadav et al., 2017). Authors suggest ADs need updated content and format to better describe the essential elements of ACP conversations, such as patients’ values and goals, and the individual’s care preferences. Outcome Across studies, there are various measures of ACP completion. Frequently, ACP programs are evaluated at the healthcare system level by data obtained from documents. The most common outcome measure is EOL treatment wishes followed by ACP/AD/EOL care discussions (Biondo et al., 2016). Biondo et al. (2016) note identifying the quality of ACP conversations is challenging to evaluate and may be assessed by patient outcomes. A recent multidisciplinary Delphi panel ranked the importance of ACP outcome constructs and evaluated ACP interventions' success into an organizing framework to define successful patient-centered ACP (Sudore, Heyland, et al., 2018). Among the top three patient-centered outcomes were: (1) care consistent with goals; (2) patient chooses a surrogate; (3) documentation of the surrogate. The authors raised caution regarding the challenges of measuring “care consistent with goals” and matching most recently documented goals. Research is needed to explore how individuals want ACP conversations started and outlined, support providers in introducing ACP, and increase public understanding (Rietjens et al., 2020). Internal Evidence/ Setting Generated Data In a small primary care office affiliated with a large healthcare organization in Southwest Arizona, patients rarely discuss ADs or ACP during their Medicare Annual Wellness Visits (AWV). For AWVs or new patient appointments, patients complete a form with only one 8 ADVANCE CARE PLANNING 9 question addressing ADs. Time is a significant barrier limiting provider initiation of ACP conversations. If ADs or ACPs are not addressed during the visit, there is little to no follow-up regarding ACP discussion. Reluctance to discuss EOL care is another observed barrier for both patients and providers. The Care Coordinator and Social Worker note these conversations would be easier to discuss if they happened before the patient was facing a dramatic decline in health status. A provider also identified a lack of follow-up scheduling appointments to address ACP or provide information when patients express interest. At least one provider does not routinely document ACP status or conversations on further investigation of documentation practices. Within the charting system, there is a notice that ACP is required for “Welcome to Medicare” visits (WMV) and is optional for initial AWV and subsequent AWVs. Further, within the EHR, there is a template for AWVs that includes checkboxes for ACP discussions/documentation and patient information regarding ADs. One provider noted she was not aware there was a template for this type of visit. Initial interest in ADs and ACP led to examining the current evidence to determine a better intervention for documenting the completion of ADs. This literature review led to the clinically relevant PICO question, "In the primary care setting, how do adults who receive ACP information before annual wellness visits compared to those who receive standard care affect the completion of an advance directive?" Evidence Synthesis Search Strategy An exhaustive literature review was performed in the following databases: Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, PsychINFO, and The Cochrane Library. These databases were selected for their relevance to the topics of AD and ADVANCE CARE PLANNING 10 ACP. Moreover, these databases are known for their rigor, medical relevance, research base, and peer review. Keywords included: adult(s) AND advance care planning OR advance directives with filters applied to publication dates between 2016 – 2021, peer-reviewed journal articles, and the English language yielded 325 results in CINAHL, 702 results in PubMed, 254 results in PsychINFO, and 61 results in Cochrane Reviews. Intervention terms were not specifically identified as the search became too narrow. Rather, operational terms were used: education, patient education, and promotion. The outcome was specified with the terms: completion, knowledge, attitudes, and electronic medical record. Mesh and Boolean terms were also used to broaden the search relevancy. CINAHL Additional search terms were added to include community, outpatient, or home, resulting in 764 articles. The last search included prior search information with the addition of the term education, resulting in 18 articles. PubMed Secondary searches included additional filters for Meta-Analysis, Randomized Controlled Trial, and Systematic Review, resulting in 69 articles. Searches that included community-dwelling, outpatient, and primary care were too narrow of a search, resulting in only two articles. Further searches with the original search terms and limits, in addition to primary care and completion, resulted in 64 articles. PsychINFO Another search in PsychINFO included community-dwelling and annual wellness exam, resulting in 21 articles. Ancillary searches included patient education, alerts, and electronic ADVANCE CARE PLANNING 11 notifications, resulting in 34 articles. With the addition of the term Medicare, 8 studies were finally identified. Critical Appraisal and Synthesis of Evidence After a thorough literature search of ACP in primary care, and the application of rapid critical appraisal tools, 10 randomized control trials, and systematic reviews were selected for further analysis. All of the studies are high-level, meaning there is a lower risk of bias and are more applicable to a broader range of people. Most of the studies were conducted in the US or included a majority of studies from the US. All studies were performed within the last five years (2016-2021), and most were inferred to use the Cognitive Behavioral Model (CBM) as a theoretical framework. Six of the studies disclosed sources of funding and bias were minimal or none declared. Significant homogeneity was apparent in demographics, most participants were White women with a mean age in their 60s-70s. Only one study included an intervention developed for Spanish-speaking participants (Sudore, Schillinger, et al., 2018). Four of the studies identified participants with lower health literacy or education levels. One study randomized 200 patients to receive the intervention, with 2294 participants in the control group (Tieu et al., 2017). The number of participants was heterogeneous across studies, ranging from 91 – 2526 (see Appendix A, Table 1). On further analysis, the majority of studies utilized a form of ACP education with a reminder system. In addition, most studies included an outcome measure of the documentation of ADs in the EHR and a discussion of ADs. Several of the studies conclude multi-level interventions, including system-level changes, could provide the greatest impact on increasing the completion rate of ADs. The systematic reviews found relatively low levels of evidence for ADVANCE CARE PLANNING 12 various interventions. Several of the studies utilized low-cost or free interventions (see Appendix A, Table 2). Conclusions The literature includes various instruments that report positive findings in the documentation of ADs or ACP discussions in the EHR, however, there is a lack of consistent evidence regarding the efficacy of one single tool. There is overall low-quality evidence for structured communication tools to assist with EOL discussions in ambulatory care settings which may increase the completion of ACP. However, there is compelling evidence to suggest that interventions targeting more than one step in the ACP process have greater increases in ACP completion. Using this information, interventions targeted to routine Medicare Wellness Visits (MWVs) with the use of standardized templates, patient education, and reminders, can feasibly increase the documentation of ADs and ACP conversations in the EHR. Theoretical Framework & Implementation Framework Theory Application The Social Cognitive Theory (SCT) was selected to describe the complex relationship between variables that can influence an individual’s decision to engage in ACP. SCT describes how individuals regulate their behavior, considering an individual’s past experiences and the environment in which the behavior would occur (Bandura, 1989). The central components of the SCT are behavioral factors, environmental factors, and personal cognitive factors (See Appendix B, Figure B1). These components exert bidirectional influence on one another to achieve behavior change. Some areas of influence may be stronger than others and the influences may occur at different times. A person’s age, gender, ethnicity, health status, personal expectations, beliefs, and goals regarding ACP can shape and drive their behavior to complete ADs. In ADVANCE CARE PLANNING 13 addition, social factors, such as who prompts the conversation of ACP and the relationship between provider and patient can affect the environment. Environmental factors related to ACP include time constraints for patient visits, the use of appropriate templates, and whether providers view ACP as a process that should be revisited annually or as a patient’s health status changes. Most of the studies did not implicate the use of SCT in their design, however many of these elements appear to be used in evaluating the documentation of ADs. Implementation Framework The Rosswurm and Larrabee model for evidence-based practice was developed from theoretical and research literature based on evidence-based practice and change theory (see Appendix B, Figure 2). This model serves as a guide for practitioners through the process of evidence-based practice and has been tested in the acute care setting (Rosswurm & Larrabee, 1999). The first step is to assess for change in practice through the collection of internal data and comparison to external data. With the identification of a problem in one part of practice, stakeholders can be recruited to participate in discussing and detailing the problem. The next step is to define the problem and link it to interventions and outcomes. The following step synthesizes the research evidence with a critical appraisal of the literature. Then, practitioners design a change in practice using the research evidence, environmental variables, and stakeholder feedback to develop the study protocol. Next, implementation of a pilot study with close monitoring of the process with follow-up reinforcement of the intervention. The data is collected and interpreted with the inclusion of staff opinions. The final step describes the implementation of the new practice into the standard of care. The steps outlined in the Rosswurm and Larrabee Model are in alignment with the requirements of a doctoral quality improvement project. The investigator can proceed through ADVANCE CARE PLANNING 14 the steps in numerical order, return to a previous step, or begin again as warranted by the situation. The Rosswurm and Larrabee Model will serve as the implementation framework for this doctoral project. At this stage, the first three steps of the model have been completed. The next step is to design the intervention, identify resources necessary for the project, plan the study, and define outcomes of interest. After design and approval from internal review boards, the next step will be the implementation of the intervention and evaluation of the process and outcomes. Finally, the results of the intervention will be evaluated to determine if the results support practice change and presented to key stakeholders. Implications for Practice Change Recent research indicates the most successful interventions that increase the completion of ADs are aimed at a combination of patient, provider, and system levels, over multiple visits (Risk et al., 2019). Person-to-person interaction was found to be a strong contributing factor compared to more fixed interventions. Also, most studies utilized some form of reminders to patients or staff regarding ACP discussions. Internal evidence at this practice site indicates there are gaps in workflow and follow-through that lead to missed opportunities to discuss ACP. Additionally, stakeholders identified that templates called “SmartSets”, often used by providers for MWVs, do not contain prompts regarding AD. This leads to missed opportunities for ACP discussion and lack of documentation in the chart, and ultimately failing to meet Medicare requirements as part of the initial WMV visit. Key stakeholders note patients often complete a Health Risk Assessment with medical assistants at the start of the MWV. This is an opportune time to ask patients if they are interested in learning more about ADs. When patients acknowledge an interest, it is the duty of the healthcare provider to provide information regarding ADs. The feasibility of the intervention will ADVANCE CARE PLANNING 15 be met by a free AD information packet provided by the Office of Arizona Attorney General, Mark Brnovich (Arizona Attorney General, 2021). This information will be available in print with funding supported by key stakeholders at the site. Stakeholders also suggest providing a tip sheet to providers regarding coding and presentation regarding the implementation of the study at the clinical site. Routine check-ins with staff and other stakeholders throughout project implementation will ensure the intervention is timely, informational, and addresses the needs of the patient. Barriers will be evaluated with input from stakeholders to collectively develop solutions to these issues. Educational materials will be provided in English, most patients at this site list English as their primary language. All components of any deliverables will remain available to patients and providers to be used on a continual basis. Baseline data regarding the number of patients without a documented AD prior to their MWV will be collected from a preintervention chart review. Follow-up data after the intervention will be collected to measure outcomes of AD and ACP discussion documentation in the chart from a chart review. If the results indicate a significant positive effect, the goal of the project will be to present to the Chief Medical Officer and Regional Medical Directors the results and incorporate questions regarding ADs in the provider template for all MWVs and implement the intervention on a larger scale. Potential Outcomes The design of the intervention will be developed with sustainability, feasibility, and quality improvement. If the results of this study demonstrate that patients are responsive to early AD education and providers begin to code for ACP discussions, tracking ACP conversations will become easier and the providers will ensure they fulfill Medicare requirements during their visits. Normalizing the conversation of ACP with annual visits can create a ripple effect, prompting patients to discuss their wishes and beliefs with family members and their providers. ADVANCE CARE PLANNING 16 Ideally, most people should have some form of AD on file in case of an emergency. ADs decrease the burden on family members to make difficult decisions and allow some comfort that providers are following the expressed wishes of the patient. The ultimate goal is to provide care at EOL that is consistent with the goals and wishes of the patient. Methods Ethical Considerations Four ethical principles provide the foundation for this doctoral-level project: autonomy, beneficence, justice, and nonmaleficence. Providers approached to participate in this project reserve the right to autonomy, which is the freedom to make one’s own decisions (American Nurses Association [ANA], 2015). The project adheres to this principle by respecting the individual’s right to choose to participate after receiving sufficient information to make an informed decision (ANA, 2015, Provision 3.2). Participants received full written information regarding potential risks and benefits of participation, offering opt-in to participate, and notification they can opt out of participation at any time. The goal of this project is to increase the frequency of ACP conversations with primary care providers, which guides patient care at end-oflife and is based on the principle of beneficence. Beneficence refers to benefitting others, by preventing or removing harm, and serving the patient’s best interests (ANA, 2015). The project will adhere to this principle by providing patient education on ACP after patients express interest in further information. This project also follows the ethical principle of justice, whereby each person will be treated equally (ANA, 2015). Provider documentation practices will be reviewed for all patients who present for their annual Medicare Wellness visit. Nonmaleficence is the final principle, which represents a duty not to harm and to stabilize unavoidable harm with improved outcomes (ANA, 2015). This project has little to no foreseeable harm anticipated, although it may ADVANCE CARE PLANNING 17 produce discomfort for the individual in having conversations regarding end-of-life. A letter of support was obtained from the Practice Manager at the Primary Care office (Appendix C). This project was deemed non-research by the organization’s Institutional Review Board (IRB) and received approval from the Network Nursing Research Council to begin the quality improvement project (Appendix D). The Arizona State University IRB approved the project as an Initial Study (Appendix E). Informed consent was obtained from participants prior to starting the project (Appendix F). Practice Setting and Participants The project site was a primary care office affiliated with a large healthcare organization in the Southwestern United States. The office has four physicians, two nurse practitioners, one social worker, one office manager, and several front- and back-office staff members. The education and recruitment of providers were held during the quarterly provider meeting at the end of the workday. Support staff were invited to participate and received education on ACP at the following morning huddle meeting. The participants contributed a portion of the meeting time and did not receive any direct or indirect compensation for participation in the education session. Inclusion criteria are all providers and support staff at this location. No providers or support staff were excluded as all have the potential to encounter patients at MWVs. Exclusion criteria are providers whose primary language is not English. Intervention This project was constructed in a pre-post design with an educational intervention and follow-up data collection on billable ACP rates in addition to ACP education and AD documentation. Providers voluntarily attended a 10-minute structured education session about ADVANCE CARE PLANNING 18 ACP that included verbal discussions and written material. The written material included a tip sheet for billable International Classification of Diseases-10, Current Procedural Terminology, and Healthcare Common Procedure Coding System codes, and a screenshot of how to find documentation templates appropriate for visit type. Participants completed a Level of Confidence subscale of the Knowledge, Attitudinal, and Experiential Survey on Advance Directives (KAESAD) survey to assess provider confidence in ACP before the intervention (Jezewski et al., 2005). The total time to complete the survey was approximately 5 minutes. The education session included information on the importance of ACP discussions, finding the documentation templates that correspond to MWVs, and billable codes for the service. The program educated providers through verbal instruction and written materials. There was the additional time allotted for questions and discussion of ACP materials and surveys. Support staff received education regarding the importance of ACP conversations and changes their workflow to facilitate these conversations. Patients presenting for a MWVs complete a Health Risk Assessment, a tool currently in use with the organization. If patients report they would like more information regarding ADs, living will, or end-of-life planning, the medical assistant (MA) or licensed practical nurse (LPN) will attach the ACP information packet to the binder clip outside the exam room door. However, if the patient declines information on ADs, living will, or end-oflife planning, no changes in the workflow are taken by the MA/LPN. Providers routinely review documents posted outside the exam room door before conducting patient visits. The ACP packet serves as a visual reminder for providers to discuss ACP with patients during their visit and can serve as an educational handout for patient education. Providers will then conduct their visits, document, and bill in the EHR. ADVANCE CARE PLANNING 19 The intervention and provider survey was conducted in October 2021. Data collection occurred between October 2021 and January 2022, and data analysis occurred between March and April of 2022. The final presentation and development of this report took place between March and April of 2022 with project dissemination in April and May 2022. Outcome Measures The primary outcome of this project is to increase the occurrence and documentation of ACP conversations during Medicare Wellness visits through staff facilitated prompts and provider education on ACP documentation and billing practices. A secondary goal is to increase the completion rate of advance directives related to the increased frequency of advance care planning conversations between provider and patient. The data will be collected from the patient’s MWV note in the EHR record by the organization’s Information Technology department for the three months pre-intervention compared to the data three months post-intervention. Instruments A questionnaire was developed by the investigator to collect data to assess provider documentation practices of ACP, preparedness for ACP conversations, and barriers to ACP discussions (Appendix G). Providers also completed a Level of Confidence subscale of the Knowledge, Attitudinal, and Experiential Survey on Advance Directives (KAESAD) developed by Mary Ann Jezewski, RN, PhD, FAAN to assess their confidence in Advance Care Planning conversations (Jezewski et al., 2005). Permission was granted by Dr. Jezewski to reproduce this portion of the instrument with the understanding that it would not be published or attached to this report. This portion of the survey contained 10 questions on a five-point Likert scale that measured the confidence in ACP ADVANCE CARE PLANNING 20 (Cronbach α= 0.95). The reliability and validity of this instrument were established by registered nurses and do not apply to the general public. Data Collection & Analysis Provider surveys were administered at the intervention, and data collection from Medicare wellness visits was collected three months before and three months post-intervention. The rate of ACP codes billed by providers was tracked by the organization’s Information Technology department. All data analysis was performed using IntellectusStatistics™. Chi-squared will be conducted to compare the two different samples, prior to implementation of the intervention and following the implementation to determine the difference in responses. Provider surveys will be evaluated using descriptive statistics and aggregate data. Budget The total cost for the project was estimated at $2,190.00 USD (Appendix H). In-kind support in the amount of $1,790.00 USD was provided by the project site. Education materials were $5.00 USD per provider. Results The intervention was implemented on October 19, 2021. A retrospective chart review revealed 145 patients were seen for their MWV in the three months before the intervention, and 106 patients were seen for a MWV in the three months after the intervention. A statistical significance calculator was used to evaluate the significance of the following findings. Of the 251 MWVs, 21 (8%) had an AD documented, significantly less than the nationally reported rate of 37.7% (p < 0.05, z = -2.39) (Yadav et al., 2017). Comparing the 145 MWVs pre-intervention (10 had an AD completed before the visit, 0 completed an AD after the visit) and 106 MWVs post-intervention (10 had an AD completed before the visit, and 1 completed an AD after), the ADVANCE CARE PLANNING 21 results were ns (p = 0.126). Although not significant, only one patient had completed an AD after the intervention which is clinically significant and supports a practice change. Provider Surveys Qualitative feedback from the survey indicates reminders and easily accessible resources may help to facilitate conversations. In addition, the provider noted they do not recommend follow-up appointments to discuss ACP. Additional barriers to ACP conversations are forgetting to discuss ACP during the visit, and that they are not confident in implementing institutional policies and procedures for ADs. One provider returned a completed survey; therefore, it is unknown if these factors are consistent across all providers. Although this feedback cannot be evaluated by statistical analysis, it does provide clinical significance and support practice change progress through the identification of barriers to implementing ACP conversations. Descriptive Findings Descriptive statistics were calculated to determine the frequencies and percentages for Race, Gender, AgeGroup, AD documentation in the chart (ADdoc), and AD date of service documentation (ADdts) for all MWV during the data collection period. The most frequently observed patient for a MWV was White or Caucasian (n = 240, 95.62%), Male (n = 144, 57.37%), 65-74 years old (n = 164, 65.34%), no AD documented (n = 230, 91.63%), and no date for ADdts (n = 230, 91.63%). In addition, descriptive statistics were calculated to determine the frequencies and percentages for patients with a documented AD during the data collection period, including Race, Gender, AgeGroup, ADdts, and VisitType. The most frequently observed patients with a documented AD were White or Caucasian (n = 21, 100.00%), Male (n = 12, 57.14%), aged 75 or older (n = 11, 52.38%), AD documentation on 09/09/2020 (n = 3, 14.29%), and seen for an Annual Wellness Visit, subsequent (n = 19, 90.48%). These findings ADVANCE CARE PLANNING 22 suggest interventions targeting ACP during MWV should account for these demographics in implementing a practice change. However, the exact visit date where ACP conversations or education led to AD documentation cannot be determined from this data. Advance Directives The following Chi-square Test of Independence and Fisher Exact Tests were run to examine whether the specified values were independent: MWV date of service (MWVdts) and ADdts; AgeGroup and ADdoc; Gender and ADdoc; and AgeGroup and ADdts. The results of the Chi-square test for MWVdts and ADdts were not significant based on an alpha value of .05, χ2(324) = 336.00, p = .311, suggesting that MWVdts and ADdts could be independent of one another. The results of the Fisher exact test were not significant based on an alpha value of .05, p = 1.000, suggesting that MWVdts and ADdts could be independent of one another. The results of the Chi-square test for AgeGroup and ADdoc were not significant based on an alpha value of .05, χ2(3) = 5.37, p = .147, suggesting that AgeGroup and ADdoc could be independent of one another. The results of the Fisher exact test were not significant based on an alpha value of .05, p = .103, suggesting that AgeGroup and ADdoc could be independent of one another. The results of the Chi-square test for Gender and ADdoc were not significant based on an alpha value of .05, χ2(1) = 0.00, p = .982, suggesting that Gender and ADdoc could be independent of one another. The results of the Chi-square for Gender and ADdts were not significant based on an alpha value of .05, χ2(19) = 18.30, p = .502, suggesting that Gender and ADts could be independent of one another. The results of the Fisher exact test were not significant based on an alpha value of .05, p = .702, suggesting that Gender and ADdts could be independent of one another. The results of the Chi-square for AgeGroup and ADdts were not significant based on an alpha value of .05, χ2(57) = 60.89, p = .338, suggesting that AgeGroup ADVANCE CARE PLANNING 23 and ADdts could be independent of one another. The results of the Fisher exact test were not significant based on an alpha value of .05, p = .104, suggesting that AgeGroup and ADdts could be independent of one another. Although these findings are not statistically significant, they do imply that the observed frequencies were not significantly different than the expected frequencies. Additionally, the intervention was implemented without additional staff or added workload. Interviews with stakeholders reveal the intervention was successfully incorporated into the clinic workflow and supports sustainability beyond the project timeframe. Providers have readily accessible ACP education material that is a visual reminder and functions as an educational handout for patients. Discussion By utilizing visual reminder tools, such as the ACP packet, the intervention was successful in increasing the documentation of AD after a MWV. The one additional AD documented after the MWV, although not statistically significant, does imply that the intervention was successful. Patients may return at future visits with completed ADs or request visits to discuss ACP, however, due to timeline limitations, these findings cannot be included in the data. The intervention was incorporated into the current clinical practice and required no additional staff or extensive training. Providers and staff were receptive to ACP education and actively participated in its discussion. Support from the site champion, office manager, and staff facilitated the implementation of this intervention. The cost of the intervention was relatively small which adds to the sustainability of the intervention. Limitations and Barriers ADVANCE CARE PLANNING 24 There were significant limitations and barriers to successfully evaluating the occurrence and documentation of ACP in the EHR. Project development and implementation in partnership with a large healthcare organization offered many communication challenges. Also, due to the timeline of the project and the annual nature of the MWVs, a pre-/post-direct comparison was not possible. The most challenging barrier was the inconsistent sites for ACP documentation in the EHR. Additionally, there are multiple locations where patients can document their ACP, including with attorneys, health care providers out-of-state, and the Arizona Healthcare Directives Registry. Individual chart review for all patients seen for MWVs to determine if ACP conversations or education were documented was not possible. Evaluation of ADs in the EHR is not a direct comparison for ACP, although it is a good indicator that these conversations do occur. Patients may return at any time in the future to document their AD in the EHR and may not be closely tied to a MWV. Additionally, there was minimal provider participation in the survey. A more robust response could have provided additional insight into barriers or limitations to ACP from the provider’s perspective. Implications The findings from this project indicate there was some measure of success in using visual reminders to facilitate ACP conversations during MWVs. Additionally, provider education on ACP documentation and Medicare requirements increases Medicare compliance. A low-cost intervention that provides a visual reminder and an education handout for patients is a sustainable tool to support ACP during MWV in primary care. Recommendations for Further Study This project highlights the need for further study of ACP in primary care. Future studies should evaluate the use of checkboxes in the EHR templates to increase the compliance rate. ADVANCE CARE PLANNING 25 Checkboxes are already used in the EHR templates, however, the boxes for ACP are not included in all visit types for MWVs. Additionally, a review of the workflow processes at the site revealed there is a need to facilitate the documentation of ADs in the EHR. Further investigation into follow-up and reminders for the patients to bring in their ADs to the provider’s office could increase the number of ADs documented. Conclusion Primary care providers can have a significant impact on the EOL care needs of patients. Addressing ACP during wellness visits provides an opportunity to plant the idea or broaden the conversation to increase the patients understanding of their options. The literature identifies many positive benefits of ACP and ADs, for patients, their loved ones, providers, and the healthcare system. ACP should be addressed early and revisited as a patient’s condition or wishes change. Addressing ACP is especially important for patients with chronic diseases and can be easier to address while in relatively good health. Documentation of ADs can provide EOL care consistent with the patients’ wishes and reduce unnecessary costs to the healthcare system. The purpose of this project was to evaluate the impact of ACP education and a reminder system on the occurrence of ACP conversations and their documentation in the EHR during MWVs. Despite the lack of statistically significant findings, the results were clinically significant and support the sustainability of this intervention. One patient returned with completed ADs after their MWV post-intervention, providers and staff increased their knowledge of ACP and ACP documentation, additional barriers to ACP were identified, and the 106 patients seen postintervention had the opportunity to take home an ACP education packet for review. Due to the timeline of the project, it is possible that the patients seen after the intervention may return at a future visit with some form of ACP completed. ADVANCE CARE PLANNING 26 References American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethicsfor-nurses/coe-view-only/ Arizona Attorney General. (2021, October). Life care planning: Advance directives for making your health care decisions. https://www.azag.gov/sites/default/files/docs/seniors/lifecare/2021/LCP_Complete_Packet-fillable.pdf Bandura, A. (1989). Social cognitive theory. Annals of child development, 6, 1-60. https://www.uky.edu/~eushe2/Bandura/Bandura1989ACD.pdf Barker, P. C., Holland, N. P., Shore, O., Cook, R. L., Zhang, Y., Warring, C. D., & Hagen, M. G. (2021). The effect of health literacy on a brief intervention to improve advance directive completion: A randomized controlled study. Journal of Primary Care & Community Health, 12, 1-8. https://doi.org/10.1177/21501327211000221 Biondo, P. D., Lee, L. D., Davison, S. N., & Simon, J. E. (2016). How healthcare systems evaluate their advance care planning initiatives: Results from a systematic review. Palliative Medicine, 30(8), 720–729. https://doi.org/10.1177/0269216316630883 Centers for Disease Control and Prevention. (2018, April 30). Give peace of mind: Advance care planning. https://www.cdc.gov/aging/advancecareplanning/index.htm Chin, J. H., & Mansori, S. (2018). Social marketing and public health: A literature review. Journal of Marketing Management and Consumer Behavior, 2(2), 48-66. https://www.academia.edu/36750381/Social_Marketing_and_Public_Health_A_Literatur e_Review ADVANCE CARE PLANNING 27 Curtis, J. R., Kross, E. K., & Stapleton, R. D. (2020). The importance of addressing advance care planning and decisions about do-not-resuscitate orders during novel Coronavirus 2019 (COVID-19). JAMA, 323(18), 1771-1772. https://doi.org/10.1001/jama.2020.4894 Devnani, R., Slaven, J. E., Bosslet, G. T., Montz, K., Inger, L., Burke, E. S., & Torke, A. M. (2017). How surrogates decide: A secondary data analysis of decision-making principles used by the surrogates of hospitalized older adults. Journal of General Internal Medicine, 32(12), 1285–1293. https://doi.org/10.1007/s11606-017-4158-z Field, M. J., Cassel, C. K., Committee on Care at the End of Life, & Institute of Medicine. (1997). Approaching death: Improving care at the end of life. National Academies Press. http://ebookcentral.proquest.com/lib/asulib-ebooks/detail.action?docID=3375542 Fine, R. L., Yang, Z., Spivey, C., Boardman, B., & Courtney, M. (2016). Early experience with digital advance care planning and directives, a novel consumer-driven program. Baylor University Medical Center Proceedings, 29(3), 263–267. https://doi.org/10.1080/08998280.2016.11929430 Gabbard, J., Pajewski, N. M., Callahan, K. E., Dharod, A., Foley, K. L., Ferris, K., Moses, A., Willard, J., & Williamson, J. D. (2021). Effectiveness of a nurse-led multidisciplinary intervention vs usual care on advance care planning for vulnerable older adults in an accountable care organization: A randomized clinical trial. JAMA Internal Medicine, 181(3), 361–369. https://doi.org/10.1001/jamainternmed.2020.5950 Institute of Medicine. (2015). Dying in America: Improving quality and honoring individual preferences near the end of life. National Academies Press. https://doi.org/10.17226/18748 ADVANCE CARE PLANNING 28 Jezewski, M.A., Brown, J. K., Wu, Y.-W. B., Meeker, M. A., Feng, J.-Y., & Bu, X. (2005). Oncology nurses’ knowledge, attitudes, and experiences regarding advance directives. Oncology Nursing Forum, 32(2), 319-327. https://doi.org/10.1188/05.ONF.319-327 Johnson, S. B., Butow, P. N., Kerridge, I., Bell, M. L., & Tattersall, M. H. N. (2018). How well do current measures assess the impact of advance care planning on concordance between patient preferences for end-of-life care and the care received: A methodological review. Journal of Pain and Symptom Management, 55(2), 480–495. https://doi.org/10.1016/j.jpainsymman.2017.09.008 Levoy, K., Buck, H., & Behar-Zusman, V. (2020). The impact of varying levels of advance care planning engagement on perceptions of the end-of-life experience among caregivers of deceased patients with cancer. American Journal of Hospice and Palliative Medicine®, 37(12), 1045–1052. https://doi.org/10.1177/1049909120917899 Lum, H. D., Dukes, J., Daddato, A. E., Juarez‐Colunga, E., Shanbhag, P., Kutner, J. S., Levy, C. R., & Sudore, R. L. (2020). Effectiveness of advance care planning group visits among older adults in primary care. Journal of the American Geriatrics Society, 68(10), 23822389. https://doi.org/10.1111/jgs.16694 Myers, J., Cosby, R., Gzik, D., Harle, I., Harrold, D., Incardona, N., & Walton, T. (2018). Provider tools for advance care planning and goals of care discussions: A systematic review. American Journal of Hospice & Palliative Medicine, 35(8), 1123-1132. https://doi.org/10.1177/1049909118760303 Myrick, K. L., Ogburn, D. F., & Ward, B. W. (2019). Percentage of office-based physicians using any electronic health record (EHR)/electronic medical record (EMR) system and physicians that have a certified EHR/EMR system, by U.S. state: National electronic ADVANCE CARE PLANNING 29 health records survey, 2017 [Data set]. National Center for Health Statistics. https://www.cdc.gov/nchs/data/nehrs/2017_NEHRS_Web_Table_EHR_State.pdf National Institute on Aging. (2018a). Advance care planning: Health care directives. National Institute of Health. Retrieved February 9, 2021 from https://www.nia.nih.gov/health/advance-care-planning-health-care-directives National Institute on Aging. (2018b). Advance care planning: tips from the National Institute of Aging. National Institute of Health. https://order.nia.nih.gov/sites/default/files/2018-03/advance-planning-tip-sheet.pdf Oczkowski, S. J., Chung, H., Hanvey, L., Mbuagbaw, L., & You, J. J. (2016). Communication tools for end-of-life decision-making in ambulatory care settings: A systematic review and meta-analysis. PLoS ONE, 11(4), 21. https://doi.org/10.1371/journal.pone.0150671 Portz, J. D., Lum, H. D., Bull, S., Boxer, R. S., Bekelman, D. B., Ford, K. L., Gleason, K., Casillas, A., & Bayliss, E. A. (2020). Perceptions of patient portal use for advance directive documentation among older adults with multiple chronic conditions. Journal of Social Work in End-of-Life & Palliative Care, 16(3), 238–249. https://doi.org/10.1080/15524256.2020.1771806 Rietjens, J., Korfage, I., & Taubert, M. (2020). Advance care planning: The future. BMJ Supportive & Palliative Care. Advance online publication. https://doi.org/10.1136/bmjspcare-2020-002304 Risk, J., Mohammadi, L., Rhee, J., Walters, L., & Ward, P. R. (2019). Barriers, enablers and initiatives for uptake of advance care planning in general practice: a systematic review and critical interpretive synthesis. BMJ Open, 9(9). https://doi.org/10.1136/bmjopen2019-030275 ADVANCE CARE PLANNING 30 Roberts, A. W., Ogunwole, S. U., Blakeslee, L., & Rabe, M. A. (2018). The population 65 years and older in the United States. U.S. Census Bureau. https://www.census.gov/content/dam/Census/library/publications/2018/acs/ACS-38.pdf Rolnick, J. A., Oredeko, F., Cooney-Zingman, E., Asch, D. A., & Halpern, S. D. (2021). Comparison of web-based and paper advance directives: A pilot randomized clinical trial. American Journal of Hospice & Palliative Medicine, 38(3), 230-237. https://doi.org/10.1177/1049909120940210 Rosswurm, M. A., & Larrabee, J. H. (1999). A model for change to evidence-based practice. Image: Journal of Nursing Scholarship, 31(4), 317–322. https://doi.org/10.1111/j.15475069.1999.tb00510.x Schichtel, M., Wee, B., Perera, R., Onakpoya, I., Albury, C., & Barber, S. (2019). Cliniciantargeted interventions to improve advance care planning in heart failure: a systematic review and meta-analysis. Heart, 105(17), 1316–1324. https://doi.org/10.1136/heartjnl2019-314758 Sudore, R. L., Heyland, D. K., Lum, H. D., Rietjens, J. A. C., Korfage, I. J., Ritchie, C. S., Hanson, L. C., Meier, D. E., Pantilat, S. Z., Lorenz, K., Howard, M., Green, M. J., Simon, J. E., Feuz, M. A., & You, J. J. (2018). Outcomes that define successful advance care planning: A delphi panel consensus. Journal of Pain and Symptom Management, 55(2), 245-255. https://doi.org/10.1016/j.jpainsymman.2017.08.025 Sudore, R. L., Lum, H. D., You, J. J., Hanson, L. C., Meier, D. E., Pantilat, S. Z., Matlock, D. D., Rietjens, J. A. C., Korfage, I. J., Ritchie, C. S., Kutner, J. S., Teno, J. M., Thomas, J., McMahan, R. D., & Heyland, D. K. (2017). Defining advance care planning for adults: A ADVANCE CARE PLANNING 31 consensus definition from a multidisciplinary delphi panel. Journal of Pain and Symptom Management, 53(5), 821-832. https://doi.org/10.1016/j.jpainsymman.2016.12.331 Sudore, R. L., Schillinger, D., Katen, M. T., Shi, Y., Boscardin, W. J., Osua, S., & Barnes, D. E. (2018). Engaging diverse English- and Spanish-Speaking older adults in advance care planning: The PREPARE randomized clinical trial. JAMA Intern Med, 178(12), 1616– 1625. https://doi.org/10.1001/jamainternmed.2018.4657 Tieu, C., Chaudhry, R., Schroeder, D. R., Bock, F. A., Hanson, G. J., & Tung, E. E. (2017). Utilization of patient electronic messaging to promote advance care planning in the primary care setting. American Journal of Hospice and Palliative Medicine, 34(7), 665– 670. https://doi.org/10.1177/1049909116650237 Weathers, E., O’Caoimh, R., Cornally, N., Fitzgerald, C., Kearns, T., Coffey, A., Daly, E., O’Sullivan, R., McGlade, C., & Molloy, D. W. (2016). Advance care planning: A systematic review of randomised controlled trials conducted with older adults. Maturitas, 91, 101–109. https://doi.org/10.1016/j.maturitas.2016.06.016 Yadav, K. N., Gabler, N. B., Cooney, E., Kent, S., Kim, J., Herbst, N., Mante, A., Halpern, S. D., & Courtright, K. R. (2017). Approximately one in three US adults completes any type of advance directive for end-of-life care. Health Affairs, 36(7), 1244–1251. https://doi.org/10.1377/hlthaff.2017.0175 Zwakman, M., Jabbarian, L., van Delden, J., van der Heide, A., Korfage, I., Pollock, K., Rietjens, J., Seymour, J., & Kars, M. (2018). Advance care planning: A systematic review about experiences of patients with a life-threatening or life-limiting illness. Palliative Medicine, 32(8), 1305–1321. https://doi.org/10.1177/02692163187844 ADVANCE CARE PLANNING 32 Appendix A Evaluation and Synthesis Table Table A1 Quantitative Evaluation Table Citation Theory/ Conceptual Framework Design/ Method Citation: Sudore et al. (2018). Engaging diverse Englishand Spanishspeaking older adults in ACP: The PREPARE randomized clinical trial None stated; inferred Cognitive Behavioral Theory Design: RCT Country: USA Funding: Grant from the NIH NIA and a PCORI award. Bias: None declared. Purpose: Compare the efficacy of PREPARE plus the easyto-read AD vs AD alone on ACP documentatio n in the medical record and patientreported ACP engagement. Sample/ Setting N= 986 n= 505 (CG) n= 481 (IG) Demographics: F: 613 Spanish: 320 Latino or Hispanic: 499 ≤ High school ed.: 576 Setting: primary care clinics within the San Francisco Health Network. IC: 55+ y/o, spoke Eng. or Span, had 2+ chronic medical conditions, 2+ visits with PCP, and 2+ additional outpatient, inpatient, or ED visits in past year. Major Variables & Definitions IV- PREPARE materials in Eng/Span, review the AD, and provided a summary of My Wishes and website log-in. DV1Documentatio n of ACP in EHR DV2Engagement in ACP process Definitions: Measureme nt/ Instrument ation ACP Engagement Survey (α = .94), PHQ-8 (α = .85) and GAD-7 questionnair es (α = .89). Data Analysis (stats used) Findings/ Results Unpaired t tests, Χ2 tests, Fisher exact tests, Wilcoxon rank-sum test, and analysis of variance. New AD documentation at 15 mo. higher in IG vs CG (43% vs 33%; p< .001). Behavior change (97.5% vs 87.3%) and action scores (94.8% vs 78.4%) were higher in IG vs CG. Increases in all types of ACP activities were significant for Englishand Spanish-speakers (89.5% CG and 98.1% IG, p< .001). Level of Evidence; Decision for practice/ application to practice LOE: II Strengths: PREPARE and an easy-to-read AD enable patients to initiate and engage in the ACP process on their own, without the need of trained facilitators. Research staff blinded to all follow-up assessments. Weakness: Generalizability, however sample was diverse. Do not have info on questions asked of research staff when pts viewed the interventions. Study interviews and Key: ACO- accountable care organization; ACP- advance care planning; AD- advance directives; AMSTAR- Assessment of Multiple Systematic Reviews measurement tool; ANOVA- analysis of variance; AWV- Annual Wellness Visit; CG- control group; DM- decision maker; DS- databases searched; DVdependent variable; EC- exclusion criteria; EHR- electronic health record; EOL- end-of-life; GAD- generalized anxiety disorder; GoC- goals of care; GRADEGrading of Recommendations Assessment, Development, and Evaluation; HF- heart failure; IC- inclusion criteria; IG- intervention group; IV- independent variable; LOE- level of evidence; MA- meta-analysis; MDPOA- Medical Durable Power of Attorney; MOST- Medical Orders for the Scope of Treatment; Nnumber of studies (if SR) or number of population enrolled; n- number of participants; NCATS- National Center for Advancing Translational Sciences; NIANational Institute on Aging; NIH- National Institutes of Health; PCORI- Patient-Centered Outcomes Research Institute; PEM- patient electronic messaging; PCP- primary care provider; PHQ- Patient Health Questionnaire; POA- power of attorney; PTS- patients; QOC- quality end-of-life communication; RCTrandomized control trial; SR- systematic review. ADVANCE CARE PLANNING Citation Citation: Lum et al. (2020). Effectiveness of ACP group visits among older adults in primary care. Theory/ Conceptual Framework ACP Engagement Theory, Collaborativ e Learning Theory Design/ Method Design: RCT 33 Sample/ Setting Major Variables & Definitions EC: mod-severe cognitive impairment, blind/deaf, delirium, psychosis, active drug/alcohol abuse, no phone, or inability to answer consent teach-back questions in 3 attempts, or those who previously engaged in ACP. Attrition: Total retention rate was 85.9% (832 of 969). N= 110 n= 55 (CG) n= 55 (IG) PREPARE is a patientdirected, interactive, online ACP program in Eng. and Span. developed by the authors. IV- ENACT group meetings with ACP tools DV- presence of ACP documentation in the EHR Measureme nt/ Instrument ation ACP Engagement Survey (α = .94). Data Analysis (stats used) t-tests, multivariate logistic regression analyses, bivariate Pearson correlation. Findings/ Results At 6 mo f/u, 71% IG compared to 45% CG had an AD documented in the EHR (p< .001). 93% IG had a DM documented vs 73% CG (p< .001). Level of Evidence; Decision for practice/ application to practice reminder calls could have activated people to engage in ACP. Feasibility: PREPARE materials are free to the public. Licensing required for research and/or quality improvement projects. LOE: II Purpose: To Strengths: planned as test whether a pilot study and the Engaging Demographics: showed a clinically in ACP talks F: 66 meaningful effect. (ENACT) ENACT intervention M. age: 77.2 White: 87 group visits is integration with pt Country: USA Married/partnered: 69 New documentation of intervention medical care. improves ACPs at 6 months was Funding: None Postgrad education: 56 Definitions: ACP declared. significantly different in Weakness: compares Caregiver in last 12 mo.: 24 ENACT group documentatio ACP in HER at baseline: 46 visits – 8-12 to a lower cost IG (39) vs. CG (5) (p = Bias: Licensed n and PREPARE for pts for two 2intervention. .0017). Setting: University of readiness in use in the study. hr sessions, 1 20% IG did not attend Colorado Hospital Seniors ACP engagement month apart a group visit. Potential older adults Clinic. increased sig. in IG by compared and facilitated selection bias for IC: Primary care PTS age with a 22.5% (p = .02) and CG individuals with high 60+ and reviewed by PCP. by a healthcare by 7.5% increase (p = control of levels of education and EC: English not preferred; dx practitioner to mailed ACP lead discussion .05). of cognitive impairment or SES. Recruitment rate of ACP topics. materials. dementia; dx of deafness; of 13%. Key: ACO- accountable care organization; ACP- advance care planning; AD- advance directives; AMSTAR- Assessment of Multiple Systematic Reviews measurement tool; ANOVA- analysis of variance; AWV- Annual Wellness Visit; CG- control group; DM- decision maker; DS- databases searched; DVdependent variable; EC- exclusion criteria; EHR- electronic health record; EOL- end-of-life; GAD- generalized anxiety disorder; GoC- goals of care; GRADEGrading of Recommendations Assessment, Development, and Evaluation; HF- heart failure; IC- inclusion criteria; IG- intervention group; IV- independent variable; LOE- level of evidence; MA- meta-analysis; MDPOA- Medical Durable Power of Attorney; MOST- Medical Orders for the Scope of Treatment; Nnumber of studies (if SR) or number of population enrolled; n- number of participants; NCATS- National Center for Advancing Translational Sciences; NIANational Institute on Aging; NIH- National Institutes of Health; PCORI- Patient-Centered Outcomes Research Institute; PEM- patient electronic messaging; PCP- primary care provider; PHQ- Patient Health Questionnaire; POA- power of attorney; PTS- patients; QOC- quality end-of-life communication; RCTrandomized control trial; SR- systematic review. ADVANCE CARE PLANNING Citation Citation: Gabbard et al. (2021). Effectiveness of a Nurse-Led Multidisciplinar y Intervention vs Usual Care on ACP for Vulnerable Older Adults in an ACO: A RCT Theory/ Conceptual Framework None stated; inferred Cognitive Behavioral Model, ACP engagement theory. Design/ Method Design: RCT 34 Sample/ Setting nonlocal residence; or prior participation in earlier ACP group visits. Attrition: At 6 mo. f/u lost 18 (IG) and 6 (CG). N=765 n= 383- 379 (IG) n = 382- 380 (CG) Major Variables & Definitions Measureme nt/ Instrument ation Data Analysis (stats used) Findings/ Results Level of Evidence; Decision for practice/ application to practice Feasibility: Relatively low cost with reimbursement for services, including co-payments. LOE: II Strengths: pragmatic design, automated identification of eligible participants, integration of ACP documentation into EHR, with supplemental information on healthcare use. Weakness: Implementation challenges in locations without a nurse navigator or other resource limitations, no contact to controls, generalizability. IV- Previsit Weighted Generalized 160 (42.2%) IG ACP phone Charlson linear mixed documented ACP within Purpose: To discussion, Comorbidit models, Cox the EHR compared to 14 determine scheduling for y Index (α = proportional (3.7%) in CG (p< .001). whether Demographics: dyad visit in .93), hazards combining F: 455 Large increases in conjunction electronic regression naming surrogate nurse with AWV or frailty index models, Mean age 77.7 independent (α = .737), mean White: 617 decision maker, having navigators ACP visit, and Short cumulative an AD, living will, or with an EHR Comorbidities: interface a mailed ACP Portable count Renal disease: 412 POA; and completing a during packet. Mental estimator, DM w/ compl: 387 MOST form (all p< Medicare Status inverse DM w/o compl: 315 DV1 –ACP .001). AWV, discussion Questionnai probability Setting: 8 separate primary improved documentation re (α = .88), of treatment Use of billing codes care clinics in NC. QOC survey weights Country: USA IC: affiliated with an ACO, in the EHR occurred in 96(25.3%) ACP documentatio 65 or older, seen PCP in last (α = .83). with logistic IG compared to 5(1.3%) Funding: The DV2- quality n in the EHR 12 mo., multimorbidity. regression. Duke of ACP CG (p< .001). Endowment and for EC: mod-severe hearing loss, discussions vulnerable Wake Forest Definitions: 87 (85% response rate) non-English speakers, no Center for completed the QOC older adults phone # available, and ACPWise- an in the survey. Healthcare Feasibility: cost significant memory integrated Innovation and assessment was a primary care impairments. ACP EHR setting. other grants. weakness due to the Attrition: 71 deaths interface Bias: None short duration of the developed by declared. study. authors. Key: ACO- accountable care organization; ACP- advance care planning; AD- advance directives; AMSTAR- Assessment of Multiple Systematic Reviews measurement tool; ANOVA- analysis of variance; AWV- Annual Wellness Visit; CG- control group; DM- decision maker; DS- databases searched; DVdependent variable; EC- exclusion criteria; EHR- electronic health record; EOL- end-of-life; GAD- generalized anxiety disorder; GoC- goals of care; GRADEGrading of Recommendations Assessment, Development, and Evaluation; HF- heart failure; IC- inclusion criteria; IG- intervention group; IV- independent variable; LOE- level of evidence; MA- meta-analysis; MDPOA- Medical Durable Power of Attorney; MOST- Medical Orders for the Scope of Treatment; Nnumber of studies (if SR) or number of population enrolled; n- number of participants; NCATS- National Center for Advancing Translational Sciences; NIANational Institute on Aging; NIH- National Institutes of Health; PCORI- Patient-Centered Outcomes Research Institute; PEM- patient electronic messaging; PCP- primary care provider; PHQ- Patient Health Questionnaire; POA- power of attorney; PTS- patients; QOC- quality end-of-life communication; RCTrandomized control trial; SR- systematic review. ADVANCE CARE PLANNING Citation Citation: Myers et al. (2018). Provider tools for ACP and goals of care discussions: A systematic review. Country: Canada Funding: Ontario Ministry of Health and Long-Term Care Bias: None stated. Citation: Tieu et al. (2017). Theory/ Conceptual Framework Design/ Method None stated; inferred Cognitive and Behavioral Theoretical Models Design: SR of guidelines, RCTs, nonRCTs, and SRs Purpose: To outline and summarize the evidence regarding existing health-care provider tools and/or practices that address the processes for ACP or GoC discussions. 35 Sample/ Setting N: 38 DS: MEDLINE, EMBASE, and American Society for Clinical Oncology Palliative Care Symposium meeting abstracts. IC: English; pts living with chronic illness and/or their substitute DM or simulated pts; HCP tools; at least 1 outcome of interest; comparative data; noncomparative data; minimum study size 30 pts. EC: Case studies, commentaries, & editorials Major Variables & Definitions IV1: Respecting Choices IV2: Availability, current issues, and anticipation tool IV3: Making Your Wishes Known tool DV1: enable HCP to introduce ACP discussions DV2: enable HCP to facilitate ACP discussions DV3: documentation of ACP discussions Measureme nt/ Instrument ation Cochrane Risk of Bias tool; Risk of Bias In NonRandomized Studies—of Intervention s tool Data Analysis (stats used) AMSTAR Findings/ Results IV1: most often used; value based; can result in increased AD completion; increased appointment of surrogate; consistency between wishes and medical interventions; increased ACP knowledge. IV2: no significant difference with control groups. IV3: Increased HCP confidence in engaging ACP, increased satisfaction Most ACP and ADs are not scanned into EHR. Level of Evidence; Decision for practice/ application to practice LOE: I Conclusions: greatest impact for ACP is likely a system-wide approach. Weakness: Lack of consistent pt outcomes evidence to support a single tool. Tools structured for PTS/caregivers without clinical support were excluded. Lack of studies that address GoC discussions. Feasibility/Applicabil ity: Respecting Choices training has a fee, time requirement may limit provider involvement. However providers can earn CME credits. LOE: II None stated; Design: RCT N= 2526 IV1: John’s Χ2 test, 5.5% IG completed and inferred Personalized Hopkins logistic returned AD, compared n= 2326 - 2294 (CG) Cognitive Key: ACO- accountable care organization; ACP- advance care planning; AD- advance directives; AMSTAR- Assessment of Multiple Systematic Reviews measurement tool; ANOVA- analysis of variance; AWV- Annual Wellness Visit; CG- control group; DM- decision maker; DS- databases searched; DVdependent variable; EC- exclusion criteria; EHR- electronic health record; EOL- end-of-life; GAD- generalized anxiety disorder; GoC- goals of care; GRADEGrading of Recommendations Assessment, Development, and Evaluation; HF- heart failure; IC- inclusion criteria; IG- intervention group; IV- independent variable; LOE- level of evidence; MA- meta-analysis; MDPOA- Medical Durable Power of Attorney; MOST- Medical Orders for the Scope of Treatment; Nnumber of studies (if SR) or number of population enrolled; n- number of participants; NCATS- National Center for Advancing Translational Sciences; NIANational Institute on Aging; NIH- National Institutes of Health; PCORI- Patient-Centered Outcomes Research Institute; PEM- patient electronic messaging; PCP- primary care provider; PHQ- Patient Health Questionnaire; POA- power of attorney; PTS- patients; QOC- quality end-of-life communication; RCTrandomized control trial; SR- systematic review. ADVANCE CARE PLANNING Citation Utilization of patient electronic messaging to promote advance care planning in the primary care setting Country: USA Funding: None declared Bias: None recognized Theory/ Conceptual Framework Behavioral Model Design/ Method Purpose: Measure the impact of a personalized ACP electronic message on AD completion in the primary care setting. 36 Sample/ Setting n= 200 - 199 (IG) Demographics: M: 1203 F: 1290 Setting: Patients empaneled to a Mayo PCIM provider in Rochester, MN M age: 72 Need for interpreter: 40 Chronic medical conditions: HTN: 1494 Vascular disease: 589 Diabetes Mellitus: 445 IC: 65+, did not have an AD on file within EHR, and had access to Mayo Online Services system. EC: None stated Attrition: 1.3% Major Variables & Definitions PEM explaining ACP process and encouraging to complete an AD. Also included a link to an ACP workbook. DV1: ACP completion DV2: utility of completed AD Measureme nt/ Instrument ation Adjusted Clinical Group Elder Risk Assessment score (α = .94). Data Analysis (stats used) regression analyses, 2sample t test. Findings/ Results to 2% CG (OR 3.2, CI [1.6-6.3]). Additional factors associated with completion of AD: higher medical complexity (P = .017) and older age (OR per 5 year age increase 1.5, P < .001). Among those who returned ADs, IG more likely to include a personal expression of health values (P < .02). Of the 200 in the IG, 74.5% opened their electronic message. Level of Evidence; Decision for practice/ application to practice Strengths: Feasibility and utility. Materials can be tailored to target specific, at-risk populations. Sustainable. Weakness: planning needs vary and may require intensive faceto-face conversation. Must have computer access. Potential selection bias to those with greater economic security and higher health literacy. May have been exposed to other ACP awareness measures during the study time. Feasibility: low cost Citation: None stated; Design: SR N = 67 IV1: Cochrane GRADE. Use of structured LOE: I Oczkowski et inferred & MA structured risk of bias communication tools al. (2016). Cognitive DS: MEDLINE, EMBASE, communicatio tool. Randomincreased: Strengths: Rigorous effects search strategy and Communication and n tool Purpose: To CINAHL, ERIC, and the Frequency of ACP/AD model. includes a wide variety tools for EOL Behavioral conduct a SR Cochrane Database of RCTs. discussions (RR 2.31, of interventions. decisionTheory. to determine 95% CI 1.25-4.26, p = Key: ACO- accountable care organization; ACP- advance care planning; AD- advance directives; AMSTAR- Assessment of Multiple Systematic Reviews measurement tool; ANOVA- analysis of variance; AWV- Annual Wellness Visit; CG- control group; DM- decision maker; DS- databases searched; DVdependent variable; EC- exclusion criteria; EHR- electronic health record; EOL- end-of-life; GAD- generalized anxiety disorder; GoC- goals of care; GRADEGrading of Recommendations Assessment, Development, and Evaluation; HF- heart failure; IC- inclusion criteria; IG- intervention group; IV- independent variable; LOE- level of evidence; MA- meta-analysis; MDPOA- Medical Durable Power of Attorney; MOST- Medical Orders for the Scope of Treatment; Nnumber of studies (if SR) or number of population enrolled; n- number of participants; NCATS- National Center for Advancing Translational Sciences; NIANational Institute on Aging; NIH- National Institutes of Health; PCORI- Patient-Centered Outcomes Research Institute; PEM- patient electronic messaging; PCP- primary care provider; PHQ- Patient Health Questionnaire; POA- power of attorney; PTS- patients; QOC- quality end-of-life communication; RCTrandomized control trial; SR- systematic review. ADVANCE CARE PLANNING Citation making in ambulatory care settings: A SR and MA. Country: Canada Funding: Grant from Technology Evaluation in the Elderly Network. Bias: None recognized. Theory/ Conceptual Framework Design/ Method the impact of communicati on tools for EOL decisionmaking with adult PTS in ambulatory care settings on the completion of ADs, the concordance between PTS wishes and medical orders for care, and concordance between the care desired and the care received by PTS at EOL. 37 Sample/ Setting IC: RCTs or prospective observation studies with a control group in peerreviewed journals; English; PTS > 18 y/o; evaluated a communication tool in comparison to CG. EC: Interventions designed for information-sharing. Control groups had to receive either use care, a sham intervention, or a minimal/low intensity intervention. Major Variables & Definitions DV1: completion of ACP DV2: concordance between ADs and medical orders for care DV3: concordance between PTS desires and care received Definitions: Structured communicatio n tool: traditional decision aids in any format and other structured approaches to help with DM. Measureme nt/ Instrument ation NewcastleOttawa scale. National Institutes of Health rating system. Data Analysis (stats used) Findings/ Results Revman 5.3 software Kappa statistics. 0.007, low quality evidence). Completion of ADs (RR 1.92, 95% CI 1.43-2.59, p < 0.001, low quality evidence). Concordance between AD preferences and medical orders (RR 1.19, 95% CO 1.011.39, p = 0.028, very low quality evidence, 1 observational study). Concordance between care desired and received (RR 1.17, 95% CI 1.05-1.30, p = 0.004, low quality evidence, 2 RCTs). Level of Evidence; Decision for practice/ application to practice Weakness: Challenge in identifying studies of interventions that facilitate EOL decision making due to lack of consistent terminology. Highly heterogeneous populations and interventions studied. Conclusion: Structured communication tools may improve communication processes and some downstream PT outcomes, but there is uncertainty in the magnitude of effects due to low quality of evidence. No single tool is considered ‘best’. Feasibility/Applicabil ity: Not enough evidence to support a particular tool Key: ACO- accountable care organization; ACP- advance care planning; AD- advance directives; AMSTAR- Assessment of Multiple Systematic Reviews measurement tool; ANOVA- analysis of variance; AWV- Annual Wellness Visit; CG- control group; DM- decision maker; DS- databases searched; DVdependent variable; EC- exclusion criteria; EHR- electronic health record; EOL- end-of-life; GAD- generalized anxiety disorder; GoC- goals of care; GRADEGrading of Recommendations Assessment, Development, and Evaluation; HF- heart failure; IC- inclusion criteria; IG- intervention group; IV- independent variable; LOE- level of evidence; MA- meta-analysis; MDPOA- Medical Durable Power of Attorney; MOST- Medical Orders for the Scope of Treatment; Nnumber of studies (if SR) or number of population enrolled; n- number of participants; NCATS- National Center for Advancing Translational Sciences; NIANational Institute on Aging; NIH- National Institutes of Health; PCORI- Patient-Centered Outcomes Research Institute; PEM- patient electronic messaging; PCP- primary care provider; PHQ- Patient Health Questionnaire; POA- power of attorney; PTS- patients; QOC- quality end-of-life communication; RCTrandomized control trial; SR- systematic review. ADVANCE CARE PLANNING Citation Citation: Risk et al. (2019). Barriers, enablers and initiatives for uptake of ACP in general practice: a SR and critical interpretive analysis Country: Australia Funding: None declared. Bias: None declared. Theory/ Conceptual Framework Design/ Method Socioecolog ical conceptual framework Design: SR and critical interpretive synthesis. Purpose: To understand how the knowledge, attitudes and practices of clinicians and consumers in general practice are understood as barriers and/or enablers to achieving uptake of ACP. 38 Sample/ Setting Major Variables & Definitions N = 54 (majority from USA) IV1: interventions across patient level, provider level and system level DV1: barriers to ACP in general practice DV2: enablers of ACP in general practice DV3: initiatives/strat egies to increase ACP in general practice DS: Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, Scopus, ProQuest and Cochrane databases. IC: English; published in a peer-reviewed journal, primary care research with scope limited to general practice, and adult populations. EC: focus on acute care, aged care facilities, palliative care or clinical management at EOL; legal focus; mental health focus; or issues for minority groups. Measureme nt/ Instrument ation Joanna Briggs Critical Appraisal Checklist Data Analysis (stats used) Decision matrix. Findings/ Results Identified barriers: lack of pt (15 studies) and HCP understanding of roles (13), knowledge (18); provider skills and experience (18); patient (7), family (6), and HCP attitudes (9), and system issues related to time pressure (12), documentation challenges (6) and mechanisms of information sharing (5). Key enablers: doctorpatient relationship (10 studies), GP and practice nurse education and communication (8), IT systems (8), business as usual processes and protocols (11), and Models of care (10). Level of Evidence; Decision for practice/ application to practice LOE: I Strengths: Evaluated a large number of studies, majority from the USA. Weakness: Studies focused on interventions limited. Study quality varied. Lack of consistent terminology. Individual and interpersonal levels of influence were least researched. Conclusions: Interventions targeting multiple levels of influence are said to reinforce each other, with the expectation to yield greater and more sustainable interventions than targeting a single level. LOE: I Citation: None stated; Design: SR N = 13 IV1: Template of RevMan Patient-mediated Schichtel et al. inferred and MA Interventions Intervention 5.3.5 interventions using the (2019). Cognitive that promoted Description Random PTS to change Key: ACO- accountable care organization; ACP- advance care planning; AD- advance directives; AMSTAR- Assessment of Multiple Systematic Reviews measurement tool; ANOVA- analysis of variance; AWV- Annual Wellness Visit; CG- control group; DM- decision maker; DS- databases searched; DVdependent variable; EC- exclusion criteria; EHR- electronic health record; EOL- end-of-life; GAD- generalized anxiety disorder; GoC- goals of care; GRADEGrading of Recommendations Assessment, Development, and Evaluation; HF- heart failure; IC- inclusion criteria; IG- intervention group; IV- independent variable; LOE- level of evidence; MA- meta-analysis; MDPOA- Medical Durable Power of Attorney; MOST- Medical Orders for the Scope of Treatment; Nnumber of studies (if SR) or number of population enrolled; n- number of participants; NCATS- National Center for Advancing Translational Sciences; NIANational Institute on Aging; NIH- National Institutes of Health; PCORI- Patient-Centered Outcomes Research Institute; PEM- patient electronic messaging; PCP- primary care provider; PHQ- Patient Health Questionnaire; POA- power of attorney; PTS- patients; QOC- quality end-of-life communication; RCTrandomized control trial; SR- systematic review. ADVANCE CARE PLANNING Citation Cliniciantargeted interventions to improve ACP in HF: A SR and MA Country: UK Funding: None declared. Bias: None declared. Theory/ Conceptual Framework and Behavioral Theory 39 Design/ Method Sample/ Setting Major Variables & Definitions Purpose: To synthesize the evidence for interventions with the greatest potential to engage clinicians with ACP in HF. DS: CINAHL, Cochrane, Embase, ERIC, Ovid MEDLINE(SP), Ovid MEDLINE(R), Science Citation Index, Social Science Citation Index & Conference Proceedings and PsychINFO. the implementatio n of any form of ACP DV1: completion of ACP document IC: RCTs and cluster RCT of clinician-targeted interventions compared with standard professional development. EC: studies that did not explicitly include patients with heart failure or only used ACP in pediatric but not adult EOL care. Also excluded interventions only on do-notattempt-cardio-pulmonaryresuscitation orders. Definitions: Cliniciantargeted interventions – interventions designed to bring about behavior changes in HCP Measureme nt/ Instrument ation and Replication. Cochrane Collaboratio n reporting items for SR and MA. GRADE, EPOC taxonomy. Data Analysis (stats used) effects models, Egger’s Test Findings/ Results clinicians’ behavior had the greatest effect (OR, 5.23; 95% CI [2.3611.61], p<.001) on the implementation of ACP in HF followed by reminder systems (3.65; 95% CI [1.47-9.04], p = .005), educational meetings (OR, 2.35 [1.29-4.26], p=.005), and academic detailing (OR, 1.66; 95% CI [1.09-2.52], p = .02). Level of Evidence; Decision for practice/ application to practice Strengths: robust search strategy, assessed quality of evidence, rated risks of bias, explored intervention synergy with TIDieR, and performed sensitivity analysis. Almost all studies based in USA. Weakness: overall quality of evidence was moderate to low. The studies included secondary care, community or hospital settings. Feasibility/Applicabil ity: Interventions were targeted at different times around hospitalization and may not apply. LOE:II Citation: None stated; Design: RCT N = 529 IV1: guidance Rapid Randomizat Overall AD completion: inferred on completion Estimate of ion table. 21.7% Barker et al. n = 263 (IG) (2021). The cognitive Purpose: To n = 266 (CG) of AD using a Adult Strengths: include evaluate an those over 50 years, effect of health and standardized Literacy in t-tests and DV1: 22.4% IG and intervention delivered intervention Demographics: literacy on a behavioral script at 7th Medicine— Chi-square 22.2% CG, p = .94, OR designed to within a practice Age: 64 brief theory grade reading Short Form tests. 1.01, (95% CI 0.67enhance AD intervention to level 1.53). Adequate literacy setting in real time to a F: 296 (56%) Key: ACO- accountable care organization; ACP- advance care planning; AD- advance directives; AMSTAR- Assessment of Multiple Systematic Reviews measurement tool; ANOVA- analysis of variance; AWV- Annual Wellness Visit; CG- control group; DM- decision maker; DS- databases searched; DVdependent variable; EC- exclusion criteria; EHR- electronic health record; EOL- end-of-life; GAD- generalized anxiety disorder; GoC- goals of care; GRADEGrading of Recommendations Assessment, Development, and Evaluation; HF- heart failure; IC- inclusion criteria; IG- intervention group; IV- independent variable; LOE- level of evidence; MA- meta-analysis; MDPOA- Medical Durable Power of Attorney; MOST- Medical Orders for the Scope of Treatment; Nnumber of studies (if SR) or number of population enrolled; n- number of participants; NCATS- National Center for Advancing Translational Sciences; NIANational Institute on Aging; NIH- National Institutes of Health; PCORI- Patient-Centered Outcomes Research Institute; PEM- patient electronic messaging; PCP- primary care provider; PHQ- Patient Health Questionnaire; POA- power of attorney; PTS- patients; QOC- quality end-of-life communication; RCTrandomized control trial; SR- systematic review. ADVANCE CARE PLANNING Citation improve AD completion: A RCT Country: USA Funding: Gatorade Trust Bias: None declared Theory/ Conceptual Framework 40 Design/ Method Sample/ Setting Major Variables & Definitions completion rates for patients in general internal medicine clinics with a single brief ambulatory intervention followed by several reminder calls. Also sought to evaluate intervention effectiveness based on health literacy of patients. Adequate literacy: 264 White: 234 (63.1%) Medicare: 270 (51%) Setting: Enrollment from 2 internal medicine outpatient clinics in Gainesville, Florida. IC: age 50+, English speaking, no documented AD in HER, and no diagnosis of dementia on problem list. EC: not included Attrition: 54 withdrew, 18 lost to follow-up DV1: AD completed and uploaded to EHR DV2: results of patient questionnaire Measureme nt/ Instrument ation tool (α = .98). Data Analysis (stats used) Findings/ Results Logistic regression. 28.4%, limited literacy 16.2%, p <.05. CSQ-8 (α = .83-.94) Pearson chisquare test. DV2: CSQ-8 scores high and similar in IG and CG. 85.6% CG and 87.3% IG (p = .28) felt addressing AD enhanced clinical encounter. Trend toward more agreement that addressing AD enhanced the visit: 90% limited literacy versus 82.88% adequate literacy (p = .06). Level of Evidence; Decision for practice/ application to practice diverse population. In this study, providing education materials was as effective as intervention with researcher. Large sample size, randomization. Weakness: Brief intervention. Institutional barriers prevented notification to provider that their PTS received AD materials. Feasibility: Low-cost 85.4% felt AD should intervention with lowroutinely be addressed at resource utilization. visits to the doctor, no difference between CG and IG, but more prevalent in limited compared to adequate literacy (89.6% vs 84.9%, p = .09). Citation: None stated. Design: RCT N = 91 IV1: Our Care Canadian Chi-square DV1: LOE:II Rolnick et al. Inferred Wishes Healthcare test, t-test, n = 45 (CG) 13 (28%) IG and 7 (16%) CG (p = .14). No (2021). cognitive n = 46 (IG) Evaluation and Key: ACO- accountable care organization; ACP- advance care planning; AD- advance directives; AMSTAR- Assessment of Multiple Systematic Reviews measurement tool; ANOVA- analysis of variance; AWV- Annual Wellness Visit; CG- control group; DM- decision maker; DS- databases searched; DVdependent variable; EC- exclusion criteria; EHR- electronic health record; EOL- end-of-life; GAD- generalized anxiety disorder; GoC- goals of care; GRADEGrading of Recommendations Assessment, Development, and Evaluation; HF- heart failure; IC- inclusion criteria; IG- intervention group; IV- independent variable; LOE- level of evidence; MA- meta-analysis; MDPOA- Medical Durable Power of Attorney; MOST- Medical Orders for the Scope of Treatment; Nnumber of studies (if SR) or number of population enrolled; n- number of participants; NCATS- National Center for Advancing Translational Sciences; NIANational Institute on Aging; NIH- National Institutes of Health; PCORI- Patient-Centered Outcomes Research Institute; PEM- patient electronic messaging; PCP- primary care provider; PHQ- Patient Health Questionnaire; POA- power of attorney; PTS- patients; QOC- quality end-of-life communication; RCTrandomized control trial; SR- systematic review. ADVANCE CARE PLANNING Citation Comparison of web-based and paper ADs: A pilot randomized clinical trial Country: USA Funding: grant from the National Center for Advancing Translational Science Bias: One author has received compensation from several organizations. Theory/ Conceptual Framework and behavioral theory 41 Design/ Method Sample/ Setting Major Variables & Definitions Purpose: To evaluate the potential of a selfcontained, web-based AD creation tool that could be completed anywhere and automatically transmit the directive to the EHR. Demographics: Age: 61.4 F: 48% ≥ college degree: 51% White: 77% Setting: Penn Medicine Infusion Center, Pennsylvania. IC: Adults with gastrointestinal and lung malignancies with a 5-year expected survival under 25% and active patient portal accounts. EC: no email address/no email use last month, not willing to be contacted by email, already have a living will, lack English proficiency, do not have patient portal account, or oncologist requested not to contact. Attrition: Data analyzed from all participants; 4 died, 1 withdrew DV1: New AD or ACP note in EHR, excluding only information on surrogate DM DV2: Change in satisfaction of EOL plans Definitions: Our Care Wishes – website with a series of modules designed to elicit detailed information on preferences, values, and goals and can generate document of surrogate DM Measureme nt/ Instrument ation Project questionnair e (α = 0.63.93) Data Analysis (stats used) Findings/ Results Wilcoxon rank sum. Ordinary least squares regression. Fisher exact test. statistically significant in DV1 in younger (9 of 46) versus older adults (11 of 45), (p = .57). No difference in DV1 in M (11 of 47) versus F (9 of 44), (p = .73). CG 7 (16%) completed a new AD or ACP note versus 13 (28%) IG, p = .14. DV2: Survey submitted by 30% IC versus 58% CG (p = .08). Mean score of 4 in both groups. No statistically significant change in DV2. Level of Evidence; Decision for practice/ application to practice Strengths: Results suggest larger study of web-based EHRtransferrable AD are needed. Most who accessed the site completed at least one module, 3.6 on average. Choice architecture that includes active choice and default option setting is a promising component of AD use. Weakness: Did not include those without patient portal access, study population was clinically heterogeneous and small. Feasibility: With implementation of EHR platform, this may be a feasible and accessible intervention. Key: ACO- accountable care organization; ACP- advance care planning; AD- advance directives; AMSTAR- Assessment of Multiple Systematic Reviews measurement tool; ANOVA- analysis of variance; AWV- Annual Wellness Visit; CG- control group; DM- decision maker; DS- databases searched; DVdependent variable; EC- exclusion criteria; EHR- electronic health record; EOL- end-of-life; GAD- generalized anxiety disorder; GoC- goals of care; GRADEGrading of Recommendations Assessment, Development, and Evaluation; HF- heart failure; IC- inclusion criteria; IG- intervention group; IV- independent variable; LOE- level of evidence; MA- meta-analysis; MDPOA- Medical Durable Power of Attorney; MOST- Medical Orders for the Scope of Treatment; Nnumber of studies (if SR) or number of population enrolled; n- number of participants; NCATS- National Center for Advancing Translational Sciences; NIANational Institute on Aging; NIH- National Institutes of Health; PCORI- Patient-Centered Outcomes Research Institute; PEM- patient electronic messaging; PCP- primary care provider; PHQ- Patient Health Questionnaire; POA- power of attorney; PTS- patients; QOC- quality end-of-life communication; RCTrandomized control trial; SR- systematic review. ADVANCE CARE PLANNING 42 Table A2 Synthesis Table Study Characteristics Year SR/MA/I RCT/II Sample n subjects/studies White Female Mean Age ≤ High school/Limited literacy Country Independent variables ACP Education Structured communication tool Electronic Format In-person Telephone Individual Group Clinician-directed Intervention Patient-mediated intervention Reminder system Educational meetings Link to MWV Sudore et al. 2018 Lum et al. 2020 Gabbard et al. 2021 Myers et al. 2018     986 688 603 63 576 110 87 66 77 8 759 617 455 77 38 USA USA USA Canada         Tieu et al. 2017 Oczkowski et al. 2016  Risk et al. 2019  Schichtel et al. 2019   2526 Barker et al. 2021 Rolnick et al. 2021   67 54 13 529 234 296 64 265 91 103 64 62 28 USA Canada Australia UK USA USA                           1290 72                      Key: ACPES- Advance Care Plan Engagement Survey; ACPET- Advance Care Plan Engagement Theory; CHEPQ- Canadian Healthcare Evaluation Project Questionnaire; CLT- Collaborative Learning Theory; CRB- Cochrane Risk of Bias; EFI- Electronic Frailty Index; ERA- Elder Risk Assessment; GAD-7Generalized Anxiety Disorder-7 Questionnaire; JHACG- John’s Hopkins Adjusted Clinical Group; LQ- low quality evidence; MWV- Medicare Wellness Visit; NO- Newcastle Ottawa scale; PEM- Personalized electronic message; PHQ-8- Patient Health Questionnaire-8; QOC- Quality of End-of-Life Communication Survey; REALM-SF- Rapid Estimate of Adult Literacy in Medicine-Short Form; ROBINS-I- Risk of Bias In Non-Randomized Studies of Intervention; SPMSQ- Short Portable Mental Status Questionnaire; SS- statistically significant; WCCI- Weighted Charlson Comorbidity Index.  ADVANCE CARE PLANNING Applicable Measurement Tools Framework 43 ACPES, PHQ-8, GAD-7 ACPES WCCI, EFI, SPMSQ, QOC CRB, ROBINS-I ERA, JHACG CRB, NO, NIH rating system CBT ACPET, CLT CBT, ACPET CBT CBT CBT Joanna Briggs Critical Appraisal Checklist Socioecologi cal GRADE, EPOC taxonomy REALM-SF, CSQ-8 CHEPQ CBT CBT CBT Dependent variables ACP Documentation ↑ ↑ ↑ ↑ ↑ ↑ (LQ) ↑ ↑ (not ss) ↑ (not ss) ACP Discussions ↑ ↑ ↑ (LQ) ↑ Behavior change ↑ Action change ↑ ↑ Depression ↓ Anxiety ↓ ACP billing codes ↑ Improved ↑ (VLQ) ↑ communication Findings Easy to read ACP +    online ACP ed. Focus on value-based    discussions System-level changes  Multi-level changes   Interprofessional      practice Provider education:  billing codes PEM as motivational  tool Barriers:  Knowledge/roles, documentation issues Enablers: relationship,  communication, IT Feasibility Free $ $$ Free-$ $ $ Key: ACPES- Advance Care Plan Engagement Survey; ACPET- Advance Care Plan Engagement Theory; CHEPQ- Canadian Healthcare Evaluation Project Questionnaire; CLT- Collaborative Learning Theory; CRB- Cochrane Risk of Bias; EFI- Electronic Frailty Index; ERA- Elder Risk Assessment; GAD-7Generalized Anxiety Disorder-7 Questionnaire; JHACG- John’s Hopkins Adjusted Clinical Group; LQ- low quality evidence; MWV- Medicare Wellness Visit; NO- Newcastle Ottawa scale; PEM- Personalized electronic message; PHQ-8- Patient Health Questionnaire-8; QOC- Quality of End-of-Life Communication Survey; REALM-SF- Rapid Estimate of Adult Literacy in Medicine-Short Form; ROBINS-I- Risk of Bias In Non-Randomized Studies of Intervention; SPMSQ- Short Portable Mental Status Questionnaire; SS- statistically significant; WCCI- Weighted Charlson Comorbidity Index. ADVANCE CARE PLANNING 44 Appendix B Models and Frameworks Figure 1 Social Cognitive Theory Chin & Mansori (2018). ADVANCE CARE PLANNING 45 Figure 2 Rosswurm and Larrabee’s Model for Evidence-Based Practice Rosswurm & Larrabee (1999). ADVANCE CARE PLANNING 46 Appendix C Organizational Letter of Support ADVANCE CARE PLANNING 47 Appendix D Network Nursing Research Council Approval Letter ADVANCE CARE PLANNING 48 Appendix E Arizona State University Institutional Review Board Approval ADVANCE CARE PLANNING 49 ADVANCE CARE PLANNING 50 Appendix F Participant Informed Consent ADVANCE CARE PLANNING 51 Appendix G Provider Survey ADVANCE CARE PLANNING 52 Appendix H Proposed Budget