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

1. Apply process for completing advance care planning 2. Evaluate process for efficacy of document completion 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. To improve ACP documentation for patients at high risk for COVID-19 complications and death. 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. 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. 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.