Outpatient–Focused Advance Care Planning: Telehealth Consultation for Geriatric Primary Care Patients

*Corresponding author: James S. Powers* and Lovely Abraham

Full-Text PDF:

original research



Documentation of advance care planning (ACP) in the electronic health record (EHR) is a quality measure promoted by both the Centers for Medicare and Medicaid Services (CMS) and the Department of Veterans Affairs (VA). There is no best practice model for promotion of ACP in primary care. Clinic prompts reminders from staff, and provision of forms and handouts modestly increase ACP completion. Targeted advance care planning and goals of care discussions for high-risk high-need older patients may help promote ACP in primary care.


High-risk, high-need geriatric patients were identified by the clinical assessment of need (CAN) risk calculator for a telehealth intervention by an advanced practice nurse trained in palliative care and embedded in the geriatric patient-aligned care team (Geri-PACT) and provided telehealth outreach for ACP and goals of care discussions.


At baseline the Geri-PACT panel had a 54% prevalence of ACP in the EHR. Completion of a life-sustaining treatment note (LST) increased from 39% to 74% following the telehealth intervention producing a total of 89% ACP documents in the EHR. Additionally, 9% of patients received goals of care discussions and a need for additional home and community-based services was identified for 12% of patients contacted. Outreach to three practices in an established physician referral and patient visit network which included 10 providers indicated that primary care providers desired to approach their own patients for ACP. These providers were educated and provided tools and information about CMS and VA ACP quality improvement directives.


A focused telehealth intervention performed by a nurse trained in palliative care and embedded in a geriatric patient-centered medical home was able to significantly increase ACP documentation in the EHR for elderly patients in the practice. Primary care providers place core importance on the value of the patient-clinician relationship and prefer to approach their own patients rather than rely on consultation for ACP. Education for primary care providers and provision of resources to perform ACP and goals of care discussions for their patients may be a worthwhile strategy to improve ACP completion and documentation in the EHR.


Advance directives; Primary care; Telehealth.