Initiating a structured advance care planning (ACP) process within a telephonic disease management model.

Abstract

73 Background: Utilizing a telephonic disease management (DM) model for educating and assisting patients to self-manage treatment side effects is a known element of practice quality. Yet, disease management models frequently neglect important aspects of patient education regarding end of life care. A model is needed whereby structured ACP content and processes are included within the disease management scope of work and documented accordingly. Methods: Over a nine month period, a DM model with an ACP education component was applied in a community oncology setting. Practice DM services were provided through a centralized call center and delivered telephonically for patients receiving chemotherapy. DM staff was comprised of registered nurses with oncology credentialing and ACP training. The model included an introduction of ACP principles within the first telephonic outreach to the patient, highlighting the purpose of ACP and the importance of ongoing communication of patient values and goals for care throughout the treatment trajectory. On subsequent calls, with the patient’s permission, DM staff provided education regarding potential end of life treatments and advance directives. Patient education and learning outcomes were documented in the electronic health record (EHR). Results: A total of 154 patients participated in the DM program. An introduction to ACP was provided for 131 patients (85%). EHR inclusion of patient values and goals for care was achieved for 93 patients (60%). 93 patients (60%) agreed to receive subsequent education regarding potential end of life treatment interventions. During the nine-month period, 21 patients (14%) transitioned to hospice care. Conclusions: Telephonic DM offers a realistic and sustainable option for initiating the ACP process. A key learning is that patients are frequently open with discussing end of life care while in the comfort and safety of their home. EHR documentation of ACP content and patient preferences for care is a critical step for real-time sharing of information among the clinical team. Further study is needed to determine whether this intervention has an impact on appropriate hospice enrollment and other quality end points.