1. The Research Question
Patients can experience harm when their values and goals regarding their care are unclear.
While many patients are able to elucidate their health care decisions in first person, this is not always the case. The vehicle to respect patient autonomy during times of incapacity is an Advance Care Plan (ACP).
The Institute of Medicine 2014 Report ‘Dying in America” outlined the need to increase advance care planning.
Primary care providers provide longitudinal care to patients across years and are well positioned to discuss ACP with their patients; however, ACP rates among patients in many primary care practices and regions remain suboptimal.
We wanted to know if we could increase the percentage of our primary care adult patients with advance care plans by developing and implementing a standardized process to integrate advance care planning into our primary care clinics.

2. What the Researchers Did
We developed and implemented a standardized process to address common barriers and integrate advance care planning into daily practice across our nine affiliated, academic primary care clinics, in Vermont, USA
Inter-professional work groups of primary care providers, staff, administrators and community organizations collaborated on developing protocols for advance care planning. Interventions included:
Standardized forms available at all sites in each examination room: HCA (health care agent form), ACP short form (HCA with additional 5 pages of medical choices) and COLST (clinical order of life sustaining treatment)
Development of a banner field in the electronic health record to identify if ACP documents on record and link directly to the document
Creation of health maintenance (HM) modifier to remind clinicians and staff when an ACP had not been completed
Display of ACP completion rates at the provider, site and department level within the EHR.
Analysis: An interrupted time series analysis was used to compare the rate of ACP completion at the clinic site level before and after the program implementation in January 2016.

3. What the Researchers Found
Our key finding was a statistically significant change in the rate of ACP completion after a multi-faceted intervention in our primary care ambulatory clinics.
In aggregate, the monthly rate of ACP documentation completion increased significantly in the post-intervention period.
The rate of ACP total completion following implementation was 4.16 (95% CI: 2.32, 7.46) times higher than the rate in the pre-implementation period
All practices except for two of the nine showed a significant increase in rate of ACP completion after the implementation.

4. What This Means for Clinical Practice
By implementing team-based processes with EHR support, our primary care clinics were able to increase the rate of ACP completion in adult patients.
This work was imbedded into the pre-visit planning process and coupled with health maintenance reminders.
Anecdotally, our providers and staff became more comfortable with “starting the conversation” with patients about ACPs following implementation.
We believe that other primary care practices could adopt similar protocols and help patients complete ACPs as part of their routine care.
Further research will be needed to see if our efforts translate to real outcome data such as goal-concordant end-of-life care and reductions in unnecessary health care utilization.