This study uses a validated Electronic Frailty Index (eFI), developed by WF investigators in geriatrics to help identify high-risk patients (defined as those 65 and older who have multimorbidity and either have impairments in physical function, cognition, and/or frailty). This population disproportionately was found to have <10% documentation of an Advanced Care Plan (ACP) within the electronic health record. The goal of this project is to improve advance care planning in these individuals with a focus on goals and values. This project is co-funded by The Duke Endowment and the CHI.

Project Overview: 

This study is a randomized, pragmatic, comparative effectiveness trial for determining better ways to engage multimorbid 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. Here, we define these patients as “vulnerable older adults” if they are 65 years and older who have multimorbidity plus impairments in either physical function (e.g., mobility disability), cognition, and/or frailty (defined as eFI >0.21). We propose to promote ACP conversations by utilizing the Electronic Health Record (EHR) to identify the most vulnerable primary care patients and then leveraging 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.

The proposed project is a natural extension of their role and empowers the nurses to use their skills more fully. Studies have shown the use of nurse navigators in advance care planning is feasible. To leverage these opportunities, our research will evaluate the effectiveness of enhancing patient and family engagement in Advance Care Planning through a nurse navigator-led pathway.

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, Winston Salem with a goal to enroll 630 patients into our study.  


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. 


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.