Use of a Clinically Derived Risk Calculator to Assess Advance Care Planning for Elderly Veterans in the Outpatient Setting

Abstract

Background
Only a third of Americans have completed an advance directive, however completion of advance directives helps to protect patient autonomy and promotes engagement and discussion of goals of care. Primary care physicians have the ability to longi-tudinally engage patients in effective conversations about their wishes toward end-of-life care. Electronic health record (EHR) tools can help clinicians to identify high–risk patients appropriate for advance care planning (ACP). Over 60% of deaths are out of hospital deaths.
Methods
We utilized the care assessment of need (CAN), an electronic medical record (EMR) dashboard tool available for all primary care patients treated at the Department of Veterans Affairs, to risk-stratify the 101,000 Tennessee Valley Healthcare System patient population. Patients identified as highest-risk individuals appropriate for ACP were assessed for completion of advance directives.
Results
For patients with a score of CAN-99 (12-month probability of hospitalization or death=44.8%), N=341, 63.6% had documented advance directives. Some 13.8% of CAN-99 patients received palliative care consults with 77% of these delivered during an inpa-tient stay. Another 10.5% of CAN-99 patients expired within 6 months and 39% of these received palliative care consults. Patients enrolled in the geriatric patient centered medical home (GeriPACT) were more likely to receive a palliative care consult (33% versus12%, p<0.001) and to have completed advance directives compared to patients paneled in primary care (80% versus 58%, p<0.05).
Conclusion
A clinically derived risk calculator can identify patients appropriate for ACP. High-risk patients enrolled in a geriatric clinic have a higher likelihood of palliative care consultation and ACP completion. A minority of ACP for these high-risk patients is performed in the outpatient department, suggesting an opportunity to expand ACP for high-risk patients in the outpatient setting.