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Original Investigation
January 11, 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

Author Affiliations
  • 1Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 2Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 3Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 4Section on General Internal Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 5Division of Public Health Sciences, Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 6Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
JAMA Intern Med. 2021;181(3):361-369. doi:10.1001/jamainternmed.2020.5950
Key Points

Question  Can a nurse navigator–led pathway plus an integrated health care professional–facing electronic health record (EHR) discussion documentation interface increase advance care planning (ACP) documentation among vulnerable older adults compared with usual care?

Findings  In this pragmatic, randomized effectiveness trial of 759 vulnerable older adults from 8 primary care clinics, a nurse navigator–led pathway plus an integrated health care professional–facing EHR interface resulted in higher rates of ACP documentation (42.2% vs 3.7%, P < .001) vs usual care.

Meaning  Use of a nurse navigator–led pathway and the health care professional–facing EHR interface may facilitate greater use of ACP for vulnerable older adults in outpatient primary care settings.

Abstract

Importance  Advance care planning (ACP), especially among vulnerable older adults, remains underused in primary care. Additionally, many ACP initiatives fail to integrate directly into the electronic health record (EHR), resulting in infrequent and disorganized documentation.

Objective  To determine whether a nurse navigator–led ACP pathway combined with a health care professional–facing EHR interface improves the occurrence of ACP discussions and their documentation within the EHR.

Design, Setting, and Participants  This was a randomized effectiveness trial using the Zelen design, in which patients are randomized prior to informed consent, with only those randomized to the intervention subsequently approached to provide informed consent. Randomization began November 1, 2018, and follow-up concluded November 1, 2019. The study population included patients 65 years or older with multimorbidity combined with either cognitive or physical impairments, and/or frailty, assessed from 8 primary care practices in North Carolina.

Interventions  Participants were randomized to either a nurse navigator–led ACP pathway (n = 379) or usual care (n = 380).

Main Outcomes and Measures  The primary outcome was documentation of a new ACP discussion within the EHR. Secondary outcomes included the usage of ACP billing codes, designation of a surrogate decision maker, and ACP legal form documentation. Exploratory outcomes included incident health care use.

Results  Among 759 randomized patients (mean age 77.7 years, 455 women [59.9%]), the nurse navigator–led ACP pathway resulted in a higher rate of ACP documentation (42.2% vs 3.7%, P < .001) as compared with usual care. The ACP billing codes were used more frequently for patients randomized to the nurse navigator–led ACP pathway (25.3% vs 1.3%, P < .001). Patients randomized to the nurse navigator–led ACP pathway more frequently designated a surrogate decision maker (64% vs 35%, P < .001) and completed ACP legal forms (24.3% vs 10.0%, P < .001). During follow-up, the incidence of emergency department visits and inpatient hospitalizations was similar between the randomized groups (hazard ratio, 1.17; 95% CI, 0.92-1.50).

Conclusions and Relevance  A nurse navigator–led ACP pathway integrated with a health care professional–facing EHR interface increased the frequency of ACP discussions and their documentation. Additional research will be required to evaluate whether increased EHR documentation leads to improvements in goal-concordant care.

Trial Registration  ClinicalTrials.gov Identifier: NCT03609658

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