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?
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.
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.
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.
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.
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.
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.
ClinicalTrials.gov Identifier: NCT03609658
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Gabbard J, Pajewski NM, Callahan KE, et al. 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 Intern Med. 2021;181(3):361–369. doi:10.1001/jamainternmed.2020.5950
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