Affiliation:
1. Department of Medicine, Division of Geriatrics University of California, San Francisco San Francisco California USA
2. Department of Public Health and Primary Care Ghent University Ghent Belgium
3. San Francisco VA Medical Center San Francisco California USA
Abstract
AbstractBackgroundAdvance care planning (ACP) has been reconceptualized as a health behavior. Action plans (APs), or patient‐directed mini contracts, improve behavior change. However, no prior studies have assessed whether APs can increase ACP documentation and engagement.MethodsWe included English and Spanish‐speaking primary care patients from San Francisco, ≥55 years of age, with ≥2 serious or chronic illnesses. Participants were in the intervention arm of the PREPAREforYOURcare.org trial and asked at baseline to choose 1 of 5 actions (e.g., choose a surrogate). At 6 months, we assessed whether participants completed their AP and if completion was associated with demographics, electronic health record (EHR) ACP documentation, and five‐point ACP Engagement Survey scores. We used t‐tests, chi‐squared, multivariate analysis adjusted for baseline ACP and clustering by physician, and qualitative thematic analysis to explore reasons for non‐completion.ResultsThe mean age of 586 participants was 65 ± 10 years; 44.0% women, 45.9% Spanish‐speaking, 31.4% had limited health literacy, and 43% completed an AP at 6 months; surrogate‐related (47.4%), tell others about medical wishes (33.7%), ask clinicians questions (13.7%), and decide what matters most in life (5.2%). Participants with limited versus adequate health literacy were less likely to complete an AP (25.4% vs 35.9%, p = 0.01). Completing an AP was associated with greater ACP EMR documentation 49.8% vs 35.6%, p < 0.001 (adjusted odds ratio: 2.06; 95% CI [1.43–2.97]) and engagement (adjusted five‐point scores [3.69; 95% CI 3.57–3.81 vs 3.10; 95% CI: 2.98–3.21], p < 0.001). Themes for non‐completion included not being ready and logistical issues (e.g., surrogate deceased).ConclusionsAmong English and Spanish‐speaking older adults, creating an ACP AP resulted in greater documentation and engagement. APs may help facilitate ACP behavior change as part of effective ACP interventions. Additional support may be needed for patients with limited health literacy and those facing logistical barriers.
Funder
National Institute on Aging