Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USAUnited States
Tennessee Valley Healthcare System, Nashville, Tennessee 37232, USAUnited States
Also available as PDF (figures and tables appear in the PDF).
Introduction Documentation of advance care planning (ACP) in the electronic health record (EHR) is a quality measure promoted by both the Centers for Medicare and Medicaid Services (CMS) and the Department of Veterans Affairs (VA). There is no best practice model for promotion of ACP in primary care. Clinic prompts reminders from staff, and provision of forms and handouts modestly increase ACP completion. Targeted advance care planning and goals of care discussions for high-risk high-need older patients may help promote ACP in primary care. Methods High-risk, high-need geriatric patients were identified by the clinical assessment of need (CAN) risk calculator for a telehealth intervention by an advanced practice nurse trained in palliative care and embedded in the geriatric patient-aligned care team (Geri-PACT) and provided telehealth outreach for ACP and goals of care discussions. Outcomes At baseline the Geri-PACT panel had a 54% prevalence of ACP in the EHR. Completion of a life-sustaining treatment note (LST) increased from 39% to 74% following the telehealth intervention producing a total of 89% ACP documents in the EHR. Additionally, 9% of patients received goals of care discussions and a need for additional home and community-based services was identified for 12% of patients contacted. Outreach to three practices in an established physician referral and patient visit network which included 10 providers indicated that primary care providers desired to approach their own patients for ACP. These providers were educated and provided tools and information about CMS and VA ACP quality improvement directives. Conclusion A focused telehealth intervention performed by a nurse trained in palliative care and embedded in a geriatric patient-centered medical home was able to significantly increase ACP documentation in the EHR for elderly patients in the practice. Primary care providers place core importance on the value of the patient-clinician relationship and prefer to approach their own patients rather than rely on consultation for ACP. Education for primary care providers and provision of resources to perform ACP and goals of care discussions for their patients may be a worthwhile strategy to improve ACP completion and documentation in the EHR.
Keywords: Advance directives; Primary care; Telehealth
Documentation of advance care planning (ACP) in the electronic health record (EHR) is a quality measure promoted by both the
Centers for Medicare and Medicaid Services (CMS) and the Department of Veterans Affairs (VA). There is no best practice model
for promotion of ACP in primary care. Clinic prompts reminders from staff, and provision of forms and handouts modestly
increase ACP completion. Targeted advance care planning and goals of care discussions for high-risk high-need older patients
may help promote ACP in primary care.
High-risk, high-need geriatric patients were identified by the clinical assessment of need (CAN) risk calculator for a telehealth
intervention by an advanced practice nurse trained in palliative care and embedded in the geriatric patient-aligned care team (Geri-
PACT) and provided telehealth outreach for ACP and goals of care discussions.
At baseline the Geri-PACT panel had a 54% prevalence of ACP in the EHR. Completion of a life-sustaining treatment note
(LST) increased from 39% to 74% following the telehealth intervention producing a total of 89% ACP documents in the EHR.
Additionally, 9% of patients received goals of care discussions and a need for additional home and community-based services was
identified for 12% of patients contacted. Outreach to three practices in an established physician referral and patient visit network
which included 10 providers indicated that primary care providers desired to approach their own patients for ACP. These providers
were educated and provided tools and information about CMS and VA ACP quality improvement directives.
A focused telehealth intervention performed by a nurse trained in palliative care and embedded in a geriatric patient-centered
medical home was able to significantly increase ACP documentation in the EHR for elderly patients in the practice. Primary care
providers place core importance on the value of the patient-clinician relationship and prefer to approach their own patients rather
than rely on consultation for ACP. Education for primary care providers and provision of resources to perform ACP and goals
of care discussions for their patients may be a worthwhile strategy to improve ACP completion and documentation in the EHR.
Advance directives; Primary care; Telehealth.
ne third of Americans have a completed advanced direc-
tive1 and fewer have this documented in the electronic health O
cc Copyright 2020 by Powers JS. This is an open-access article distributed under Creative Commons Attribution 4.0 International License (CC BY 4.0), which record (EHR). The Centers for Medicare and Medicaid Services
(CMS) and the Department of Veterans Affairs (VA) quality improvement objectives encourage completion of advance care plan-
ning (ACP) documents and inclusion in the EHR.2 CMS encour-
ages documentation of the appointment of agent as well as a living
will, while the VA requires a life-sustaining treatment note (LST), a
formal documentation of goals of care and ACP. There is no best
practice model of how to implement these recommendations. We
describe a telehealth outreach to high-risk high-need patients in a
VA primary care geriatric practice (Geri-PACT) utilizing a trained
nurse practitioner who was an integral part of the clinic.
The Tennessee Valley Healthcare System (TVHS) is an integrated
health care system of over 100,000 patients in middle Tennessee
comprised of 2 medical centers located 40 miles apart, and 12 community-based outpatient clinics.
In 2011, TVHS developed a geriatric patient-centered
medical home model for geriatric primary care-the geriatric patient-
aligned care team (Geri-PACT). The Geri-PACT Team consists of
the Geri-PACT provider (geriatrician or geriatric nurse practitio-
ner with an outpatient panel size of approximately 800), a social worker, a clinical pharmacist, a registered nurse care manager, a
licensed vocational nurse, and clerical staff. Geri-PACT is a special population PACT within primary care for complex geriatric and
other high-risk vulnerable veterans providing integrated, interdisciplinary assessment and longitudinal management, and coordina-
tion of both VA-sponsored and non-VA sponsored (Medicare and
Medicaid) services for patients and caregivers.3
The clinical assessment of need (CAN) is a clinical pre-
dictor of future hospitalization and death developed for VA popu-
lations. This methodology extracts predictors from 6 categories: social demographics, medical conditions, vital signs, prior year use
of health services, medications, and laboratory tests and constructs logistic regression models to predict outcomes. CAN scores are
from 1-99, with higher scores corresponding to an increased prob-
ability of future healthcare events.
We report our experience utilizing a trained advanced practice nurse who was an integral staff member of Geri-PACT to
perform ACP and goals of care discussions for high-risk patients with CAN scores between 95-99.
Our overall study was designed to meet standards for
quality improvement reporting excellence (SQUIRE) criteria, and this report meets the quality improvement minimum quality criteria
set (QI-MQCS) domains for reporting quality improvement work.6
The TVHS Institutional Review Board (IRB) has deter-
mined this study as a quality improvement initiative.
The Geri-PACT practice of 793 patients included 139 patients with
CAN scores between 95-99, with a mean probability of hospitaliza-
tion or death of 56% within 12-months. Over a six-month followup period, this high-risk population had a 10% mortality and 33.8%
were hospitalized, with 59% receiving skilled and non-skilled home
and community-based services. Some 12% of patients received
additional home and community-based services as a result of the
telehealth intervention including 5% who were referred for hospice
care (Table 1). Baseline advance care documentation in the EHR
showed 15% had appointment of agent or a living will and 39%
had LST notes giving a prevalence of 54% documentation of ACP
in the EHR at baseline. The telehealth intervention completed an-
other 35% of LST notes providing a total of 89% of this high-risk
population with ACP documentation in the EHR.
Table 1. Geri-PACT High-risk High-need Patients (CAN 95-99)
81 years mean age 16 mean number of medications 56% mean probability of event in 6 months
10% dementia 32% congestive heart failure 23% cancer diagnosis 12% stroke
56% urban 44% rural 20% home alone 69% home with caregiver 6% assisted living residence 4% long-term care facility
47% None 55% Home health services 20% Homemaker home health 4% Adult day care
90% Alive 10% Expired 33.8% Hospitalized
15% advance directive in EHR 39% VA Life Sustaining Treatment note (LST) in place 35% LST completed with telehealth call 9% GOC discussion with telehealth call 8% referred to hospice
1% specialty clinic referral 2% referred for skilled home care 4% referred for nonskilled services (ADC, respite, H/HHC) 5% Hospice referral
ADC-adult day care; advance directives-appointment of agent, living will; CAN-clinical 5 assessment of need risk score; H/HHA -homemaker, home health aide (non-skilled services); GOC-goals of care; LST-formal VA advance directive and goals of care discussion documentation.
Three affiliated practices comprising a total of 10 provid-
ers (6 physicians and 4 advanced practice nurses) in an established
physician referral and patient visit network were approached with
30-50 high-risk patients identified for each provider. These prac-
tices had strong consultation relationships with Geri-PACT, which
provided consultations for geriatric syndromes, falls, dementia, and
palliative care services. Primary care providers stressed the value of
the patient clinician relationship and expressed strong preferences
to provide advance care and goals of care discussions for their own
patients. Individual providers were given education and tools to
provide ACP discussions as well as information on CMS and VA
quality improvement directives and documentation requirements.
Providers indicated a desire to reserve referrals for selected pallia-
tive care services for individual patients.
Enhanced ACP discussions and completion of documents can
be modestly increased by utilizing in-clinic prompts and remind-
ers from staff, and provision of forms and handouts immediately 7,8 available in the clinic.7,8 These processes can be further enhanced
by the use of clinically derived risk scales to identify high-risk pa-
tients appropriate for ACP and goals of care discussions.
We found an advanced practice nurse trained in ACP dis-
cussions and who was in an integrated member of the practice
delivering a telehealth intervention as a focused outreach strategy
greatly increased ACP documentation in the EHR. The interven-
tion also identified a need for additional home and community-
based services among 12% of patients contacted.
Efforts to provide ACP discussions to affiliated primary care prac-
tices met resistance. Even though primary care providers referred
patients for other geriatric syndromes as well as palliative care
services, they appeared to wish to preserve the patient-provider
relationship for advance directive discussions. We proceeded to
educate primary care providers to facilitate discussions of ACP
and to provide the tools for appropriate CMS and VA quality im-
provement documentation in the EHR.
There are not enough board-certified palliative care clinicians to
provide all palliative care needs or ACP discussions. Many have
advocated for a generalist model of palliative care with a coor-
dinated palliative care model whereby the primary care physician
could manage many palliative care problems, reserving palliative
care consultation for more complex or refractory concerns such
as symptom management. Education to enhance the skills of all
clinicians to improve the ability to address basic palliative care
needs and ongoing palliative care management reinforces exist-
ing patient-provider relationships and may be a more sustainable
model.
Our experience validates the core importance of the pa-
tient clinician relationship and the strong preference of primary
care providers to perform these advance directive discussions with
their patients. These important discussions enhance the patient
physician relationship and come from trusted providers. Educa-
tion for primary care physicians to facilitate ACP and goals of care
discussions is appropriate, reserving consultation for palliative
care specialty concerns for selected patients. The use of telehealth
may help provide primary palliative care education to PCP’s and
increase access for specialty palliative care consultation.
The authors declare that they have no conflicts of interest.