Primary care practices lack a pathway to meet the advance care planning needs of their patient populations. We defined advance care planning as the process of supporting our patients in the understanding and sharing their personal values, life goals, and preferences regarding future medical care. Our advance care planning (ACP) intervention had three main objectives:
- Apply a predictive model to identify patients who might most benefit from ACP;
- Complete ACP-dedicated appointments with non-physician Patient Navigators;
- Use EMR tools to standardize ACP documentation and make data accessible across care settings
We piloted a population-health based pathway to provide ACP at the Duke Outpatient Clinic (DOC), and developed a model to identify and risk- stratify patients who would benefit from an ACP intervention.
Our data science model identified 480 patients appropriate for an ACP appointment. From July 1 to November 10, 2017, we completed outreach to 245 patients, scheduled 129 patients for ACP appointments, and completed 114 ACP appointments. 112 patients had completed ACP visit notes, and 103 patients had completed HCPOA forms (90%). Our social work-trained patient navigators provided bandwidth to engage patients through a new type of clinic encounter that can be reimbursed successfully through designated Medicare CPT codes for ACP.
