Another plus: better EHR documentation of patients' wishes.


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Advance care planning (ACP) can improve alignment between patient preferences for end-of-life care and the care they actually receive. But research shows that such conversations with older adults rarely take place in primary care settings, and if they do, they are poorly documented in the medical record. A new study, however, found that nurse navigator-led interventions increased the frequency of ACP discussions as well as documentation in the patients' electronic health records (EHRs).


"We showed in our study that utilizing nurse navigators to call patients to discuss why ACP is important and to complete telephone previsit ACP discussions helped prime patients prior to their provider visits, helped facilitate ACP discussions with their primary care providers, and helped move patients from a precontemplative to an action phase," said the lead author of the study, Jennifer Gabbard, MD, assistant professor of internal medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.


Published in JAMA Internal Medicine, the study sought to determine if nurse navigator-led ACP, combined with a health care professional-facing EHR interface, increased the frequency of patient participation in ACP as well as EHR documentation of advance care directives.


The study cohort comprised 759 patients from eight primary care practices in North Carolina. All were age 65 or older and had multiple comorbidities. They were randomized to either usual care or a nurse navigator-led ACP pathway. Of those assigned to the ACP pathway, 294 met the study criteria; of these, 146 consented to participate and 139 completed the intervention.


A much higher rate of ACP documentation occurred in the nurse navigator-led group than in the usual care group, 42.2% versus 3.7%. In addition, more billing for ACP planning occurred in the nurse-led group (25.3% versus 1.3%). An interesting finding was that 26% of participants wanted to discuss ACP only with their nurse navigators and did not want to continue these discussions with their primary care providers.


"I absolutely believe a navigator is a great option to assist in facilitating ACP," Shannon Parrish, RN, one of the navigators in the study, told AJN. The navigator's role is to help patients on their health care journey, which, according to Parrish, often results in building relationships with the patients "and sets the stage to help facilitate these conversations."-Roxanne Nelson


Gabbard J, et al. JAMA Intern Med 2021;181(3):361-9.