Integrated Multidisciplinary Patient and Family Advance Care Planning Trial

Wake Forest University Health Sciences146 enrolled

Overview

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.

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.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

NONE

Enrollment

146

Conditions

Advance Care Planning

Interventions

Nurse Navigator PathwayBEHAVIORAL

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 CareBEHAVIORAL

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.

Eligibility

Sex: ALLMin age: 65 Years

Medical Language ↔ Plain English

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

Locations (9)

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

Outcomes

Primary Outcomes

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.