IMPACT

Integrated Multidisciplinary Patient and Family Advance Care Planning Trial

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.

Aims

Primary Aim

Aim 1: To determine whether a nurse navigator-led ACP pathway improves having advance care planning discussions between patients and their primary care providers along with improving documentation of these discussions utilizing an innovative outpatient ACP documentation tool in the Electronic Health Record (EHR) for vulnerable older adults.

Secondarily Aim

Aim 2.1: To compare usage of ACP billing codes among patients for the nurse navigator-led ACP pathway versus usual care.

Aim 2.2: To compare documented designated surrogate decision makers and advance directive (AD) form completion rates in the EHR for the nurse navigator-led ACP pathway versus usual care.

Exploratory Aims

Aim 3.1: To compare Medical Scope of Treatment (MOST) form completion rates and documentation in the EHR for the nurse navigator-led ACP pathway versus usual care.

Aim 3.2: To compare quality of end-of-life care for patients who pass away who were in the nurse navigator-led ACP pathway versus usual care.

Aim 3.3: To compare patient healthcare utilization (inpatient hospitalizations, emergency department (ED) visits, intensive care unit (ICU) admissions and length of stay and mechanical intubations) between the nurse navigator-led ACP pathway versus usual care.

Outcomes

Primary and secondary outcomes

Our primary outcomes are documentation of advance care planning (ACP) wishes within the electronic health record along with quality of advance care planning discussions. Documentation of ACP wishes for the purpose of this study includes both advance care planning discussion documentation within the electronic health record from the nurse navigators and primary care providers. We assessed baseline and then will assess 12 and 18-month documentation rates and the date of documentation to determine the length of time from study enrollment to subsequent documentation. We will measure quality of advance care planning discussion from two different mechanism. First, a scoring mechanism was created to measure quality of ACP discussions for both the telephone ACP discussion with the nurse navigator along with provider ACP visit discussion. Second, we will use the quality about end-of-life communication (QOC) to assess quality of ACP discussion from the patient’s perspective. QOC is a 13-item instrument with an overall score and 2 subscale scores for “general communication skills” and “communication about end-of-life care.” scores range from 0 (“poor”) to 10 (“absolutely perfect”). Higher scores determine better outcomes.

Secondary outcomes were chosen to measure the full process of ACP. We will measure advance care planning billing code usage to help access ACP discussion rates. We will measure documentation of designed surrogate decision makers along with advance directive completion rates as another marker to access ACP documentation rates within the electronic health record.

Technology Transfer and Commercialization

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Research Focus Areas

Translation to Care

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IMPACT

A Deeper Look

Aims

Primary Aim

Secondarily Aim

Exploratory Aims

Outcomes