Advance care planning is underused, especially in primary care settings. In addition, tools are needed to improve health care professionals' documentation of advance care planning discussions in the electronic health record (EHR). Researchers designed a study to determine whether a nurse navigator-led advance care planning pathway combined with a health care professional-facing EHR interface improved documentation of advance care planning within the EHR for vulnerable older adults in the outpatient primary care setting. The study population included primary care patients age 65 or older who had evidence of multimorbidity and an indication of cognitive or physical impairment or frailty. The researchers created an integrated advance care planning EHR interface to allow primary care professionals to document advance care planning in a standardized manner. A total of 759 participants were randomized to the nurse navigator-led intervention or usual care.

Documented advance care planning within the EHR-the primary outcome-occurred in 42.2% of patients in the nurse navigator group compared with 3.7% in the usual care group. Those in the nurse navigator group were also more likely to name a designated surrogate decision maker; complete a medical orders for scope of treatment form; and have an advance directive, living will, or power of attorney. In addition, billing codes for advance care planning visits were used more often in the nurse navigator group. During follow-up, the number of ED visits and inpatient hospitalizations wasn't significantly different between the two groups.

Implementation of the study intervention would be more difficult in settings without a nurse navigator, the authors write. Also, the investigators note they had no contact with patients assigned to usual care and couldn't assess the long-term effect of advance care planning discussions on care delivery, the quality of medical decision making, or cost.