Outpatient–Focused Advance Care Planning: Telehealth Consultation for Geriatric Primary Care Patients.
Documentation of advance care planning in the electronic health record is a quality measure promoted by both the Centers for Medicare and Medicaid Services and the Department of Veterans Affairs. 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 risk calculator for a telehealth intervention by an advanced practice nurse trained in palliative care and embedded in the geriatric patient-aligned care team and provided telehealth outreach for ACP and goals of care discussions.
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.
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.
Palliat Med Hosp Care Open J. 2020; 6(1): 1-4. doi: 10.17140/PMHCOJ-6-133
