The IMPACT project aims to improve Advance Care Planning (ACP) in individuals considered high-risk. This project takes advantage of another Center for Healthcare Innovation (CHI) validated project, the Electronic Frailty Index (eFI) , to identify vulnerable, high-risk primary care patients: Defined as those 65 and older who have multi-morbidity and either have impairments in physical function, cognition, and/or frailty.

Once identified, patients work with nurse navigators as the first point of contact for ACP discussions. Nurse navigators already function well in engaging patients with care coordination, patient education and connections to community-based resources.

This project is co-funded by the Duke Endowment and the Center for Healthcare Innovation.

A Deeper Look

This study is a randomized, pragmatic, comparative effectiveness trial for determining better ways to engage multi-morbid older adults and their family members in Advance Care Planning (ACP) through a nurse navigator-led pathway versus usual bare.

At present, the care of vulnerable older adults is marked by fragmented health care focused on disease-based treatment, lengthy and recurrent hospital stays, and higher cost care through the end of life.
Our overall hypothesis is that in a primary care setting, the nurse navigator-led ACP pathway will result in improved provider-patient communication about goals of care and will improve ACP documentation in the EHR as compared to usual care.

We have 8 sites who are participating:

  • Thomasville Family Practice Associates, Thomasville.
  • Internal Medicine at Westchester, High Point.
  • Family and Community Medicine of Asheboro, Asheboro.
  • Claremont Family Medicine, Claremont.
  • Conover Family Medicine, Conover.
  • Wake Forest Health Network Complex Care, High Point.
  • High Point Family Medicine, High Point and Downtown Health Plaza.