Advance care planning (ACP), defined as the process of understanding, reflecting, and discussing future medical wishes, including end of life wishes,1 is a critical component of population health strategy and delivering value-based care.2 While 80% of people say that if seriously ill they would want to talk to their doctor about wishes for medical treatment towards end of life, only 7% report having this conversation with their doctor.3 Specifically at Duke Health among a population of seniors undergoing pre-op evaluation, only 53-55% report having completed a Healthcare Power of Attorney (HCPOA) or Living Will, which are important components of early stage ACP.4 Primary care is a cornerstone of population health and is a natural setting for introducing and integrating ACP. Primary care providers (PCPs) can begin the process of discussing patient preferences and facilitating discussions with sub-specialists regarding prognosis and goals of care. Yet, there lacks a population health-based pathway for ACP that engages primary care practices.

In this proposed pilot, we leverage the newly launched Maestro Care ACP activity that provides a central repository to document ACP conversations and house scanned legal documents, new Medicare billing codes for ACP Visits, and a patient-centered approach to completing legal documents for early stage ACP. We are building off of a feasibility pilot already underway at the Duke Outpatient Clinic (DOC) that tests the use of a predictive analytics tool to identify patients for early stage ACP and tests a model for scheduling dedicated ACP appointments through the scheduling hub.