Timing of Acute Palliative Care Consultation in Critically Ill Patients

The proportion of billed CMS ACP-CPT codes in Ig vs. Cg

The proportion of patients who received an ACP CMS billing codes (which took effect in January 2016), in Ig vs. Cg will be evaluated using one or both of the new CPT codes for Advance care planning (ACP) services…including the explanation and discussion of advance directives such as standard forms (with the completion of such forms, when performed) by the physician or other qualified health profession; first 30 (15-45)minutes, face to face with the patients, family member(s) and/or surrogate Code 99497; and each additional 30 (46-75 minutes)-Code 99498 (Federal Register, 2015).

Time frame: 30 days from enrolled patients' hospital discharge

Matches of care received to patient-specific preferences in Ig vs. Cg

The investigators will align treatment preferences with medical orders, replicated as reported in the study by Mack et al. Proportions of patients coded as having a match will be compared across the treatment and control groups. For everyone who gets ACP during the study, patients or their surrogates will be asked by a member of the care team-either palliative care if they are consulted, or the hospital based care team if they are not: "If you could choose, would you prefer (a) treatment that focuses on attempting to extend your time as much as possible, even if doing so means more pain and discomfort, or (b) a plan of care that focuses on relieving pain and discomfort and improving quality of life, even though that may mean not living as long.

Time frame: 1 year

Patient/family satisfaction with care in Ig vs. Cg

This outcome will be measured on a continuous scale. The net-promoter score will be measured at baseline (at randomization) and at hospital discharge for a change in value. It is measured on a scale of 1-10. Whoever signs the consent (patient of LAR) will be asked the net promoter score, and that will be reassessed by them at discharge, unless the patient has died-and the variable will then be recorded as missing. The PSQ will be administered by research assistants at the time of the patient's discharge. If the patient is incapacitated, then it will be asked of the patient's closest family caregiver. So PSQ is only at discharge of patient or available, most involved, family caregiver.

Time frame: Baseline

Amount of hospice referrals in Ig vs. Cg

Time frame: 1 year

Hospital total direct costs for the index visit in Ig vs. Cg

Time frame: 1 year

Hospital and ICU length of stay in Ig vs. Cg

Time frame: 1 year

Average days in hospice in Ig vs. Cg

Time frame: 1 year

Hospital margin contribution for the index visit in Ig vs. Cg

Time frame: 1 year

Time to consultation in Ig vs. Cg groups

Time frame: 1 year