COVID-19 and Advance Care Planning: A Unique Opportunity (QI429)

OUTCOMES: 1. Apply process for completing advance care planning 2. Evaluate process for efficacy of document completion BACKGROUND: Advance care planning (ACP) is a process to document patient preferences for future healthcare. Conversations between healthcare providers, patients, and loved ones are needed to reflect a patient's values, goals, and choices for life-sustaining treatments (LSTs). The COVID-19 pandemic highlighted the critical importance of these discussions and the need for improved patient engagement. AIM STATEMENT: To improve ACP documentation for patients at high risk for COVID-19 complications and death. METHODS: As COVID-19 surged, the VA Northern California Health Care System Hospice and Palliative Care Section (HPCS)partnered with patient aligned care teams to expand outreach to high-risk patients needing LST documentation. High risk was defined as age >80, COPD or asthma, or Care Assessment Need Score >80 (which models risk of hospitalization or death within 1 year). An experienced HPCS nurse practitioner contacted these identified patients to provide COVID-19 education, conduct a high-quality goals-of-care conversation, and complete LST documentation and other ACP needs. A representative cohort was followed up to evaluate concordance of treatment with documented preferences. RESULTS: Between March and September 2020, 910 patients were identified as high risk, of which 294 agreed to participate in the telehealth visit and complete LST documentation. Importantly, 108 (37%) patients chose DNR and other LST limitations. Additionally, 142 (48%) patients created POLST documentation and 128 (43%) completed advance directives. Over 70% of patients hospitalized received care concordant with the documented LST preferences. A follow-up survey found the outreach impactful, with LST preferences documented correctly. CONCLUSIONS AND IMPLICATIONS: Prior studies have demonstrated success at training primary providers to conduct ACP discussions, but given the limitations imposed by COVID-19 restrictions, this novel and highly cost-effective process of coupling a highly trained HPCS NP with multiple primary care teams to perform ACP was piloted with success.