Integrated Multidisciplinary Patient and Family Advance Care Planning Trial

Advance Care Planning Clinical Trial

— IMPACT  

Official title:

Integrated Approach to Patient and Family Engagement for Advance Care Planning for Vulnerable Older Adult Within an Accountable Care Organization (ACO)

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT03609658
• Other study ID #: IRB00049370
• Status: Completed
• Phase: N/A
• Start date: November 2, 2018
• Est. completion date: December 10, 2019

Study information

• Verified date: June 2021
• Source: Wake Forest University Health Sciences
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The purpose of this study is to compare ways to engage sick patients and their family members in Advance Care Planning (ACP) discussions. Two pathways will be tested, discussions using a Nurse Navigator led pathway versus usual care.

Description:

This study is a randomized, pragmatic, comparative effectiveness trial for determining better ways to engage multimorbid patients and their family members in Advance Care Planning through a Nurse Navigator led pathway versus usual care. Investigators propose to utilize Zelen's design (a more recent label/generalization for this type of design is the cohort multiple randomized controlled trial (cmRCT), a pragmatic clinical trial design whereby all participants are randomized prior to informed consent, and then only patients randomized to the interventional arm are approached for consent and subsequently enrolled in the intervention group.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 146
• Est. completion date: December 10, 2019
• Est. primary completion date: December 10, 2019
• Accepts healthy volunteers: No
• Gender: All
• Age group: 65 Years and older

Eligibility

Inclusion Criteria:

• Aged 65 or older patient within the Wake Forest/Cornerstone ACO
• Have seen their primary care provider within the Wake Forest/Cornerstone network in the past 12 months
• English speaking
• No documented Advance Directive in the EHR
• Impairments in either physical function, cognition, and/or frailty

Exclusion Criteria:

• No available proxy (e.g. in setting of cognitive impairment)
• Severe/advanced dementia
• Moderate to severe hearing loss
• Non-English speaking
• No phone number available for patient

Related Conditions & MeSH terms

• Advance Care Planning

Intervention

Behavioral:
• Nurse Navigator Pathway
In the Nurse Navigator Pathway, nurse navigators are being used as leverage to: approach qualified patients to initiate advance care planning discussions, schedule advance care planning visit with patients' primary care provider to further discuss advance care planning and to mail advance care planning resources to patients after their initial advance care planning discussion.
• Usual Care
In the Usual Care arm, there is no approach by nurse navigators to initiate advance care planning discussions and it does not have a structure advance care planning visit. Therefore, no further action is required for the patients who were randomly assigned to the usual care arm.

Locations

Country	Name	City	State
United States	Family & Community Medicine of Asheboro	Asheboro	North Carolina
United States	Claremont Family Medicine	Claremont	North Carolina
United States	Conover Family Practice	Conover	North Carolina
United States	Chronic Complex Care	High Point	North Carolina
United States	Cornerstone Internal Medicine at Westchester	High Point	North Carolina
United States	High Point Family Practice	High Point	North Carolina
United States	Thomasville Family Practice	Thomasville	North Carolina
United States	Downtown Health Plaza	Winston-Salem	North Carolina
United States	Wake Forest University Health Sciences	Winston-Salem	North Carolina

Sponsors (2)

Lead Sponsor	Collaborator
Wake Forest University Health Sciences	Duke University

Country where clinical trial is conducted

United States, 

References & Publications (69)

"Methods for Analysis of the Financing and Use of Long-Term Services and Supports," supplemental material for Rising Demand for Long-Term Services and Supports for Elderly People (June 2013), www.cbo.gov/publication/44370.

Adamson J, Cockayne S, Puffer S, Torgerson DJ. Review of randomised trials using the post-randomised consent (Zelen's) design. Contemp Clin Trials. 2006 Aug;27(4):305-19. Epub 2006 Feb 7. Review. — View Citation

Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012 Jul 7;380(9836):37-43. doi: 10.1016/S0140-6736(12)60240-2. Epub 2012 May 10. — View Citation

Bugarski V, Sakac V, Vodopivec S, Slankamenac P. Relation between personality dimensions and depressive symptoms in patients on hemodialysis. Med Pregl. 2010 May-Jun;63(5-6):305-12. English, Serbian. — View Citation

Bunn F, Burn AM, Goodman C, Rait G, Norton S, Robinson L, Schoeman J, Brayne C. Comorbidity and dementia: a scoping review of the literature. BMC Med. 2014 Oct 31;12:192. doi: 10.1186/s12916-014-0192-4. Review. — View Citation

Bunn F, Goodman C, Burn AM. Multimorbidity and frailty in people with dementia. Nurs Stand. 2015 Sep 2;30(1):45-50. doi: 10.7748/ns.30.1.45.e9816. — View Citation

Campbell SE, Seymour DG, Primrose WR; ACMEPLUS Project. A systematic literature review of factors affecting outcome in older medical patients admitted to hospital. Age Ageing. 2004 Mar;33(2):110-5. Review. — View Citation

Campitelli MA, Bronskill SE, Hogan DB, Diong C, Amuah JE, Gill S, Seitz D, Thavorn K, Wodchis WP, Maxwell CJ. The prevalence and health consequences of frailty in a population-based older home care cohort: a comparison of different measures. BMC Geriatr. 2016 Jul 7;16:133. doi: 10.1186/s12877-016-0309-z. — View Citation

Castanho TC, Amorim L, Zihl J, Palha JA, Sousa N, Santos NC. Telephone-based screening tools for mild cognitive impairment and dementia in aging studies: a review of validated instruments. Front Aging Neurosci. 2014 Feb 25;6:16. doi: 10.3389/fnagi.2014.00016. eCollection 2014. Review. — View Citation

Clegg A, Bates C, Young J, Ryan R, Nichols L, Ann Teale E, Mohammed MA, Parry J, Marshall T. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing. 2016 May;45(3):353-60. doi: 10.1093/ageing/afw039. Epub 2016 Mar 3. Erratum in: Age Ageing. 2017 Jan 17;:. — View Citation

Connors MH, Sachdev PS, Kochan NA, Xu J, Draper B, Brodaty H. Cognition and mortality in older people: the Sydney Memory and Ageing Study. Age Ageing. 2015 Nov;44(6):1049-54. doi: 10.1093/ageing/afv139. — View Citation

Dong H, Robison LL, Leisenring WM, Martin LJ, Armstrong GT, Yasui Y. Estimating the burden of recurrent events in the presence of competing risks: the method of mean cumulative count. Am J Epidemiol. 2015 Apr 1;181(7):532-40. doi: 10.1093/aje/kwu289. Epub 2015 Feb 17. — View Citation

Drubbel I, de Wit NJ, Bleijenberg N, Eijkemans RJ, Schuurmans MJ, Numans ME. Prediction of adverse health outcomes in older people using a frailty index based on routine primary care data. J Gerontol A Biol Sci Med Sci. 2013 Mar;68(3):301-8. doi: 10.1093/gerona/gls161. Epub 2012 Jul 25. — View Citation

Fine, J., & Gray, R. (1999). A Proportional Hazards Model for the Subdistribution of a Competing Risk. Journal of the American Statistical Association, 94(446), 496-509. doi:10.2307/2670170.

Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med. 2005 May-Jun;3(3):223-8. — View Citation

Fortin M, Lapointe L, Hudon C, Vanasse A, Ntetu AL, Maltais D. Multimorbidity and quality of life in primary care: a systematic review. Health Qual Life Outcomes. 2004 Sep 20;2:51. Review. — View Citation

Fortin M, Soubhi H, Hudon C, Bayliss EA, van den Akker M. Multimorbidity's many challenges. BMJ. 2007 May 19;334(7602):1016-7. — View Citation

Fried LP, Kronmal RA, Newman AB, Bild DE, Mittelmark MB, Polak JF, Robbins JA, Gardin JM. Risk factors for 5-year mortality in older adults: the Cardiovascular Health Study. JAMA. 1998 Feb 25;279(8):585-92. — View Citation

Gill TM, Allore HG, Gahbauer EA, Murphy TE. Change in disability after hospitalization or restricted activity in older persons. JAMA. 2010 Nov 3;304(17):1919-28. doi: 10.1001/jama.2010.1568. Erratum in: JAMA. 2011 Apr 6;305(13):1301. — View Citation

Glidden DV, Vittinghoff E. Modelling clustered survival data from multicentre clinical trials. Stat Med. 2004 Feb 15;23(3):369-88. — View Citation

Gómez-Batiste X, Martínez-Muñoz M, Blay C, Amblàs J, Vila L, Costa X, Espaulella J, Espinosa J, Constante C, Mitchell GK. Prevalence and characteristics of patients with advanced chronic conditions in need of palliative care in the general population: a cross-sectional study. Palliat Med. 2014 Apr;28(4):302-11. doi: 10.1177/0269216313518266. Epub 2014 Jan 8. — View Citation

Gonzalez-Colaço Harmand M, Meillon C, Bergua V, Tabue Teguo M, Dartigues JF, Avila-Funes JA, Amieva H. Comparing the predictive value of three definitions of frailty: Results from the Three-City study. Arch Gerontol Geriatr. 2017 Sep;72:153-163. doi: 10.1016/j.archger.2017.06.005. Epub 2017 Jun 17. — View Citation

Guiding principles for the care of older adults with multimorbidity: an approach for clinicians. Guiding principles for the care of older adults with multimorbidity: an approach for clinicians: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. J Am Geriatr Soc. 2012 Oct;60(10):E1-E25. doi: 10.1111/j.1532-5415.2012.04188.x. Epub 2012 Sep 19. — View Citation

Hagerty RG, Butow PN, Ellis PM, Lobb EA, Pendlebury SC, Leighl N, MacLeod C, Tattersall MH. Communicating with realism and hope: incurable cancer patients' views on the disclosure of prognosis. J Clin Oncol. 2005 Feb 20;23(6):1278-88. Erratum in: J Clin Oncol. 2005 May 20;23(15):3652. Mac Leod, Craig [corrected to MacLeod, Craig]. — View Citation

Herrin J, Harris KG, Kenward K, Hines S, Joshi MS, Frosch DL. Patient and family engagement: a survey of US hospital practices. BMJ Qual Saf. 2016 Mar;25(3):182-9. doi: 10.1136/bmjqs-2015-004006. Epub 2015 Jun 16. — View Citation

House A, Knapp P. Informed consent. Trials that use Zelen's procedure should be acceptable. BMJ. 1997 Jul 26;315(7102):251. — View Citation

http://www.gotplans123.org/.

Hubbard RE, Peel NM, Samanta M, Gray LC, Mitnitski A, Rockwood K. Frailty status at admission to hospital predicts multiple adverse outcomes. Age Ageing. 2017 Sep 1;46(5):801-806. doi: 10.1093/ageing/afx081. — View Citation

Iezzoni LI. Multiple chronic conditions and disabilities: implications for health services research and data demands. Health Serv Res. 2010 Oct;45(5 Pt 2):1523-40. doi: 10.1111/j.1475-6773.2010.01145.x. Epub 2010 Aug 2. — View Citation

Ito M, Nakajima S, Fujisawa D, Miyashita M, Kim Y, Shear MK, Ghesquiere A, Wall MM. Brief measure for screening complicated grief: reliability and discriminant validity. PLoS One. 2012;7(2):e31209. doi: 10.1371/journal.pone.0031209. Epub 2012 Feb 14. — View Citation

Julious SA. Sample Sizes for Clinical Trials. Chapman & Hall/CRC, Boca Raton, FL, 2010.

Kogan AC, Wilber K, Mosqueda L. Person-Centered Care for Older Adults with Chronic Conditions and Functional Impairment: A Systematic Literature Review. J Am Geriatr Soc. 2016 Jan;64(1):e1-7. doi: 10.1111/jgs.13873. Epub 2015 Dec 2. Review. — View Citation

Lanièce I, Couturier P, Dramé M, Gavazzi G, Lehman S, Jolly D, Voisin T, Lang PO, Jovenin N, Gauvain JB, Novella JL, Saint-Jean O, Blanchard F. Incidence and main factors associated with early unplanned hospital readmission among French medical inpatients aged 75 and over admitted through emergency units. Age Ageing. 2008 Jul;37(4):416-22. doi: 10.1093/ageing/afn093. Epub 2008 May 16. — View Citation

Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, Meinow B, Fratiglioni L. Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev. 2011 Sep;10(4):430-9. doi: 10.1016/j.arr.2011.03.003. Epub 2011 Mar 23. Review. — View Citation

Meghani SH, Hinds PS. Policy brief: the Institute of Medicine report Dying in America: Improving quality and honoring individual preferences near the end of life. Nurs Outlook. 2015 Jan-Feb;63(1):51-9. doi: 10.1016/j.outlook.2014.11.007. Epub 2014 Dec 11. — View Citation

Menotti A, Mulder I, Nissinen A, Giampaoli S, Feskens EJ, Kromhout D. Prevalence of morbidity and multimorbidity in elderly male populations and their impact on 10-year all-cause mortality: The FINE study (Finland, Italy, Netherlands, Elderly). J Clin Epidemiol. 2001 Jul;54(7):680-6. — View Citation

Moorman SM, Carr D, Kirchhoff KT, Hammes BJ. An assessment of social diffusion in the Respecting Choices advance care planning program. Death Stud. 2012 Apr;36(4):301-22. — View Citation

Mori M, Yoshida S, Shiozaki M, et al.

Morrison RS. Research priorities in geriatric palliative care: an introduction to a new series. J Palliat Med. 2013 Jul;16(7):726-9. doi: 10.1089/jpm.2013.9499. Epub 2013 May 30. — View Citation

Pajewski NM, Williamson JD, Applegate WB, Berlowitz DR, Bolin LP, Chertow GM, Krousel-Wood MA, Lopez-Barrera N, Powell JR, Roumie CL, Still C, Sink KM, Tang R, Wright CB, Supiano MA; SPRINT Study Research Group. Characterizing Frailty Status in the Systolic Blood Pressure Intervention Trial. J Gerontol A Biol Sci Med Sci. 2016 May;71(5):649-55. doi: 10.1093/gerona/glv228. Epub 2016 Jan 11. — View Citation

Pate A, Candlish J, Sperrin M, Van Staa TP; GetReal Work Package 2. Cohort Multiple Randomised Controlled Trials (cmRCT) design: efficient but biased? A simulation study to evaluate the feasibility of the Cluster cmRCT design. BMC Med Res Methodol. 2016 Aug 26;16(1):109. doi: 10.1186/s12874-016-0208-1. — View Citation

Prentice R, Williams B, and Peterson A. On the regression analysis of multivariate failure time data. Biometrika 1981;68:373-379. .

Quiñones AR, Markwardt S, Botoseneanu A. Multimorbidity Combinations and Disability in Older Adults. J Gerontol A Biol Sci Med Sci. 2016 Jun;71(6):823-30. doi: 10.1093/gerona/glw035. Epub 2016 Mar 11. — View Citation

Reeves D, Howells K, Sidaway M, Blakemore A, Hann M, Panagioti M, Bower P. The cohort multiple randomized controlled trial design was found to be highly susceptible to low statistical power and internal validity biases. J Clin Epidemiol. 2018 Mar;95:111-119. doi: 10.1016/j.jclinepi.2017.12.008. Epub 2017 Dec 19. — View Citation

Rietjens JA, Korfage IJ, Dunleavy L, Preston NJ, Jabbarian LJ, Christensen CA, de Brito M, Bulli F, Caswell G, Cerv B, van Delden J, Deliens L, Gorini G, Groenvold M, Houttekier D, Ingravallo F, Kars MC, Lunder U, Miccinesi G, Mimic A, Paci E, Payne S, Polinder S, Pollock K, Seymour J, Simonic A, Johnsen AT, Verkissen MN, de Vries E, Wilcock A, Zwakman M, van der Heide Pl A. Advance care planning--a multi-centre cluster randomised clinical trial: the research protocol of the ACTION study. BMC Cancer. 2016 Apr 8;16:264. doi: 10.1186/s12885-016-2298-x. — View Citation

Roccaforte WH, Burke WJ, Bayer BL, Wengel SP. Reliability and validity of the Short Portable Mental Status Questionnaire administered by telephone. J Geriatr Psychiatry Neurol. 1994 Jan-Mar;7(1):33-8. — View Citation

Rockwood K, Mitnitski A, Song X, Steen B, Skoog I. Long-term risks of death and institutionalization of elderly people in relation to deficit accumulation at age 70. J Am Geriatr Soc. 2006 Jun;54(6):975-9. — View Citation

Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci. 2007 Jul;62(7):722-7. Review. — View Citation

Roe L, Normand C, Wren MA, Browne J, O'Halloran AM. The impact of frailty on healthcare utilisation in Ireland: evidence from the Irish longitudinal study on ageing. BMC Geriatr. 2017 Sep 5;17(1):203. doi: 10.1186/s12877-017-0579-0. — View Citation

Rothman MD, Leo-Summers L, Gill TM. Prognostic significance of potential frailty criteria. J Am Geriatr Soc. 2008 Dec;56(12):2211-16. doi: 10.1111/j.1532-5415.2008.02008.x. — View Citation

Ryan A, Wallace E, O'Hara P, Smith SM. Multimorbidity and functional decline in community-dwelling adults: a systematic review. Health Qual Life Outcomes. 2015 Oct 15;13:168. doi: 10.1186/s12955-015-0355-9. — View Citation

Schoenborn NL, Cayea D, McNabney M, Ray A, Boyd C. Prognosis communication with older patients with multimorbidity: Assessment after an educational intervention. Gerontol Geriatr Educ. 2017 Oct-Dec;38(4):471-481. doi: 10.1080/02701960.2015.1115983. Epub 2016 Feb 17. — View Citation

Shear KM, Jackson CT, Essock SM, Donahue SA, Felton CJ. Screening for complicated grief among Project Liberty service recipients 18 months after September 11, 2001. Psychiatr Serv. 2006 Sep;57(9):1291-7. — View Citation

Signorielli N: Physical disabilities, impairment and safety,mental illness, and death. In: Mass Media Images and Impact on Health: A Sourcebook. Westport, CT: Greenwood Press, 1993, pp. 37-42.

Smith SM, O'Dowd T. Chronic diseases: what happens when they come in multiples? Br J Gen Pract. 2007 Apr;57(537):268-70. — View Citation

Smith SM, Soubhi H, Fortin M, Hudon C, O'Dowd T. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ. 2012 Sep 3;345:e5205. doi: 10.1136/bmj.e5205. Review. — View Citation

Sudore RL, Barnes DE, Le GM, Ramos R, Osua SJ, Richardson SA, Boscardin J, Schillinger D. Improving advance care planning for English-speaking and Spanish-speaking older adults: study protocol for the PREPARE randomised controlled trial. BMJ Open. 2016 Jul 11;6(7):e011705. doi: 10.1136/bmjopen-2016-011705. — View Citation

Sudore RL, Boscardin J, Feuz MA, McMahan RD, Katen MT, Barnes DE. Effect of the PREPARE Website vs an Easy-to-Read Advance Directive on Advance Care Planning Documentation and Engagement Among Veterans: A Randomized Clinical Trial. JAMA Intern Med. 2017 Aug 1;177(8):1102-1109. doi: 10.1001/jamainternmed.2017.1607. — View Citation

Sudore RL, Landefeld CS, Barnes DE, Lindquist K, Williams BA, Brody R, Schillinger D. An advance directive redesigned to meet the literacy level of most adults: a randomized trial. Patient Educ Couns. 2007 Dec;69(1-3):165-95. Epub 2007 Oct 17. — View Citation

Taylor AW, Price K, Gill TK, Adams R, Pilkington R, Carrangis N, Shi Z, Wilson D. Multimorbidity - not just an older person's issue. Results from an Australian biomedical study. BMC Public Health. 2010 Nov 22;10:718. doi: 10.1186/1471-2458-10-718. — View Citation

Torgerson D. The use of Zelen's design in randomised trials. BJOG. 2004 Jan;111(1):2. — View Citation

Torgerson DJ, Roland M. What is Zelen's design? BMJ. 1998 Feb 21;316(7131):606. Review. — View Citation

Townsend A, Hunt K, Wyke S. Managing multiple morbidity in mid-life: a qualitative study of attitudes to drug use. BMJ. 2003 Oct 11;327(7419):837. — View Citation

Turner G, Clegg A; British Geriatrics Society; Age UK; Royal College of General Practioners. Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age Ageing. 2014 Nov;43(6):744-7. doi: 10.1093/ageing/afu138. Review. — View Citation

U.S. Census Bureau. International database. Table 094. Midyear population, by age and sex. Available at http://www.census.gov/population/www/projections/natdet-D1A.htmlExternal Web Site Icon.

Vogeli C, Shields AE, Lee TA, Gibson TB, Marder WD, Weiss KB, Blumenthal D. Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med. 2007 Dec;22 Suppl 3:391-5. Review. — View Citation

Yamaguchi T, Maeda I, Hatano Y, Mori M, Shima Y, Tsuneto S, Kizawa Y, Morita T, Yamaguchi T, Aoyama M, Miyashita M. Effects of End-of-Life Discussions on the Mental Health of Bereaved Family Members and Quality of Patient Death and Care. J Pain Symptom Manage. 2017 Jul;54(1):17-26.e1. doi: 10.1016/j.jpainsymman.2017.03.008. Epub 2017 Apr 24. — View Citation

Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012 Jan 11;307(2):182-92. doi: 10.1001/jama.2011.1966. Review. — View Citation

Zelen M. A new design for randomized clinical trials. N Engl J Med. 1979 May 31;300(22):1242-5. — View Citation

* Note: There are 69 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Other	Number of Medical Scope of Treatment (MOST) Discussions	Reported as the number of completed MOST discussion within the new ACP template and/or scanned form in the EHR	End of Study (Month 13)
Other	After-death Bereaved Family Member Interview	The After-death bereaved family member interview measures the quality of end of life care. Interview is analyzed utilizing Q-pro software for qualitative data.	Month 29
Other	Frequency of Patient Healthcare Utilization	Frequency is measured by the number of healthcare events recorded in the EHR.	End of Study (Month 13)
Other	Cost of Patient Healthcare Utilization	Cost of patient healthcare utilization per group	End of Study (Month 13)
Other	Provider Satisfaction With the Intervention Scale	This is a likert scale total score (0-78). Higher scores denotes better outcomes	Month 11
Other	Number of Protocol Deviations	The number of protocol deviations will be reported to measure the fidelity of study implementation.	End of Study (Month 13)
Other	Usability of the ACP Documentation Tool (ACPWiseTool)	Measured by the System Usability Scale (SUS) survey. Likert Scale of strongly disagree, disagree, neutral, agree, and strongly agree. Score ranges from 1 to 5. Higher score equates higher usability.	End of Study (Month 13)
Primary	Number of Patient's Documented Advance Care Planning Discussion- Nurse Navigator	Reported as the number of documentations completed in the newly created ACP note template for nurse navigator note templates.	End of Study (Month 13)
Primary	Number of Patient's Documented Advance Care Planning Discussions - Provider	Reported as the number of documentations completed in the newly created ACP note template for provider note templates.	End of Study (Month 13)
Primary	Quality of Advance Care Planning Discussion - Nurse Navigator	Measured by the newly created ACP note template for both nurse navigator (score ranging from 0-8). Score of 5 or higher determines better outcome.	End of Study (Month 13)
Primary	Quality of Advance Care Planning Discussion - Provider	Measured by the newly created ACP note template for provider note templates (score ranging from 0-15). Score of 8 or higher in the provider template determines better outcome.	End of Study (Month 13)
Primary	Quality of Advance Care Planning Discussion From the Patient's Perspective	Measured by the Quality about End of Life (EOL) Communication (QOC), The instrument is reported as 2 subscales: "general communication skills" and "communication about end-of-life care." Score range for the subscales is 1-11 Higher scores determine better outcomes.	End of Study (Month 13)
Secondary	Advance Care Planning Billing Code Usage	ACP billing codes: 99497 and 99498 usages will be recorded	End of Study (Month 13)
Secondary	Number of Designated Surrogate Decision Makers	Reported as the number of designated surrogate decision makers documented in Electronic Health Record (EHR).	End of Study (Month 13)
Secondary	Advance Directive Completion	Reported as the number of scanned advance directive documents in the EHR.	End of Study (Month 13)