Year: 2021
Type: article
Study design: Clinical Trial
Abstract: Addressing advance care planning (ACP) promotes care aligned with patients' goals, completion of advance directives (AD), and designation of surrogate decision makers.1, 2 However, ACP is challenging for primary care providers (PCPs) due to barriers such as limited time and awareness.3 These challenges are compounded by language and literacy barriers in the safety net.4 Group visits can provide a supportive peer environment to address both chronic and episodic care needs.5 Although few studies have explored group visits to address ACP, none were led by the patient's own PCP during a usual primary care session.6, 7 We assessed the feasibility and impact on patient knowledge, AD completion, and patient and care team satisfaction of a model for ACP group visits led by the PCP during a routine clinic session. The ACP group visit model launched in July 2017 at a Los Angeles County Department of Health Services adult primary care clinic serving low-income, publicly insured, or uninsured persons. Nine ACP group visits (seven English, two Spanish; 27 total patients and nine guests) were conducted over 6 months. Five internists, two family physicians, and two family nurse practitioner PCPs were trained on group visit facilitation and ACP counseling (Supplementary Data S1). PCPs facilitated 1-h ACP group visits embedded in their regular 4-h clinic schedule, in English or Spanish and co-facilitated by a social work staff member or certified medical assistant who provided additional cultural and linguistic support. The PCP gave a brief didactic presentation, followed by group discussion about ACP to prompt reflection and dialogue. The ACP group visits created space for PCPs to teach patients and guests about ACP and ADs and offer assistance with AD completion. Surveys were collected pre- and post-ACP group visit to assess satisfaction and ACP knowledge rated on a five-point Likert scale. PCPs and care team members completed a post-pilot survey to assess feasibility and satisfaction with ACP group visits. Bivariate analyses of demographic characteristics items were conducted for English- and Spanish-speaking groups. Changes in ACP knowledge question scores were assessed using exact McNemar chi-square tests stratified by language of group visit. Operational metrics including visit volume and no-show rate were compared with usual care (three patients per hour, with a 20% no-show rate in 2017). AD completion was measured 1-year post-ACP group visits by electronic health record (EHR) abstraction. This study was granted exemption by the Olive View-UCLA IRB. The average age of participating patients was 69.1 years (67.3 years English-speaking, 72.3 years Spanish-speaking) and 37% of group visit participants were Spanish-speaking (Supplementary Table S1). Before the group visit, 50% of the English-language patients agreed they had a clear understanding of ACP; afterward, 94% agreed (Figure 1, p-value = 0.008). Only one Spanish-speaking patient reported a clear understanding of ACP pre-group visit, compared with 100% afterward (p-value = 0.003). Confidence in ability to complete an AD increased from 62% to 94% after the group visit for English-speaking patients (p-value = 0.03) and 20% to 90% for Spanish-speaking patients (p-value = 0.02). Although belief in the importance of having an AD increased, the change was not significant. All patients who completed the post-visit survey agreed they would recommend the ACP group visits to other patients. None of the participating patients had ACP documentation in the EHR prior to the ACP group visits; 1 year later, over half had completed an AD (65% English; 30% Spanish). Most care team members (94%, 17/18) agreed that ACP group visits are preferred to usual care, citing higher quality care and improved relationships with patients (Supplementary Table S2). The average number of patients per PCP participating in a 1-h group visit was 2.7, comparable to usual clinic productivity. In our study, PCP-led ACP group visits were feasible and well-accepted by patients and primary care team members in the healthcare safety net and promoted patient knowledge of ACP. One year after the study, over half of participants had completed an AD, compared with 9%–25% in studies of similar populations.4, 8 PCPs facilitating the ACP group visit for their patients may provide familiarity and trust. ACP group visits that maintain provider productivity overcome two barriers to addressing ACP in primary care: lack of time and competing priorities. Amidst the COVID-19 pandemic, which disproportionately impacts older and marginalized persons, ACP serves a more critical function than ever.9 PCP-led ACP group visits may facilitate engagement in ACP and AD completion in the safety net, while maintaining productivity and providing a satisfying experience for the entire healthcare team. Support for this research is from Center for Care Innovations, Spreading Solutions that Work grant, Olive View-UCLA Medical Center, and NIH National Center for Advancing Translational Science (NCATS) UCLA CTSI Grant Number UL1TR001881. The authors acknowledge the tools available at ACPdecisions.org and PrepareForYourCare.org. The authors of this manuscript have no conflicts to report. Heather B. Schickedanz and Karen J. Kim directed the study concept and design, acquisition of subjects and/or data, analysis and interpretation of data, and preparation of the manuscript. Rhonda Polzin participated in the study concept and design and approved the manuscript. Stefanie D. Vassar participated in the analysis and interpretation of data and approved the manuscript. Arleen F. Brown reviewed the study design, participated in the analysis and interpretation of data, and provided edits and approved the manuscript. Center for Care Innovations; Spreading Solutions that Work grant; UCLA CTSI, Grant/Award Number: UL1TR001881 None. Supplementary Data S1: ACP group visit training resources and detailed demographic characteristics for ACP group visit attendees (Supplementary Table S1) and responses for staff survey (Supplementary Table S2). Supplementary Table S1: Patient demographic characteristics by language. Supplementary Table S2: Advance care planning (ACP) post-visit staff survey (n = 18) Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
DOI: 10.1111/jgs.17098
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W3140800985