We rarely talk about death — especially our own. When our patients avoid the subject, they often end up receiving fragmented care that is misaligned with their wishes, goals, and commitments. Research shows that they are more likely to have medicalized deaths in places other than where they wish to spend their final moments and that their loved ones are more likely to be more stressed, anxious, and depressed than they need be.1, 2, 3
Advance Care Planning (ACP) offers a solution to some of these challenges. At its most basic, ACP is “a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care.” 4 Whether through formally executed advance directives or an ongoing conversation between a patient, their family, and their primary care provider (PCP), the goal is the same: to create a shared understanding of how a patient wants to be cared for in the event of a serious illness or injury.
Challenges to Implementing Advance Care Planning and How to Overcome Them
Effectively implementing ACP can be difficult and intimidating, leading to substantial gaps in the frequency of the service. For instance, Pearl practices range from 0-90% of their attributed patients having received a prior ACP claim. There are a variety of well-documented barriers to conducting ACP — especially in the time-constrained setting of the typical 15-minute primary care visit:
- It’s an emotionally complex topic: Not all patients are prepared or willing to engage with the issue. A patient who doesn't feel that they have a strong relationship with their PCP or who lacks trust in health care in general may also be less inclined to engage in conversations around their goals for care at the end of their lives.
- It’s another demand on clinicians’ time: There aren’t enough hours in the day for primary care physicians to do their jobs.5 Most clinicians have the training and empathy required to have these nuanced and emotionally complex conversations — but the conversations also take time, which is unfortunately a commodity that few PCPs have to give.
- It’s a fluid and evolving conversation: ACP is seldom completed in a single conversation; things change and plans evolve. Patients have new life experiences that may change how they think about health care needs; new technology may be developed that could dramatically alter life-saving therapies; the list goes on. Having a well-structured and ongoing conversation around ACP is a challenge that few primary care practices are set up for.
Recommendations for Effective Advance Care Planning
At Pearl, we seek to equip our clinicians with the tools necessary to perform high-value ACP. PCPs occupy a privileged space as it relates to helping patients think through what they value and how their various commitments can be brought to bear in their goals for end-of-life care. Clinicians can raise potential scenarios for care that a patient ought to consider and help the patient understand the implications of the different options available to them.
This year, our data science team is working to identify the patients who are most likely to benefit from ACP, thereby assisting time-constrained PCPs to efficiently offer the service. We are also pursuing partnerships with other experts in the field so our community can leverage best practices from industry experts. To that end, here are a few recommendations for effective, life-giving Advance Care Planning:
- Utilize existing resources to help guide the conversation: While ACP is a process, it’s also important to memorialize the conversation with discrete documents: living wills, advanced directives, and/or provider orders for life-sustaining treatment (POLST).6 POLST forms, in particular, can be clearly interpreted during high-stakes clinical decisions, and we strongly recommend ensuring that these are shared with local healthcare facilities. It’s also worth adding appropriate ICD-10s to your patient records, such as Z66 for Do Not Resuscitate (DNR) orders.
- Prioritize patients who lack ACP and are most in need: Our extensive research and internal analysis has demonstrated that sicker patients (particularly those at risk of unplanned hospitalization) are more likely to benefit from ACP. Given the competing demands that PCPs face, using well-defined criteria to prioritize the patients who are most in need of ACP can help reduce the added burden of time.
- Create workflows that support the time-intensive nature of nuanced, complex discussions, and keep the conversations going: Given the time-intensive and evolving nature of ACP discussions, creating workflows that help support these conversations on an ongoing basis is essential. For example, by creating a process to proactively identify patients who are due for Annual Wellness Visits (AWV), scheduling those visits, and incorporating ACP into the AWV, clinicians can help their patients create ACPs and have a regular, annual touchpoint to check in with their patients and update the ACPs as needed.
- Take advantage of payment incentives: ACP is a reimbursable service (CPT 99497 and 99498) and, when paired with an AWV, it has no associated patient copay. Pearl also offers internal incentives to our participating practices when ACP is provided to the patients in greatest need, as defined by their frailty cohorts.
The Benefits of Advance Care Planning for Patients and Clinicians
The benefits to Advance Care Planning far outweigh the challenges. Patients with well-documented ACPs in place are more likely to consume fewer health care resources, to be more satisfied by the care they do receive, and to feel less anxious about their deaths than those who haven’t discussed their wishes for end-of-life care.7, 8
By utilizing ACP, clinicians are able to accompany their patients through these challenging decisions. In doing so, PCPs help make space for their patients to enjoy fulfilling lives while also potentially avoiding unnecessary, sometimes futile, and often costly clinical interventions that are inconsistent with a patient’s commitments and goals.
At Pearl, we believe that thoughtful ACP will greatly improve the alignment of primary care. Having these essential conversations is an important step toward helping patients feel more fulfilled and less anxious about what the future holds. If you’re interested to learn more about how Pearl is supporting our provider partners with ACP, consider contacting us!
Our Technology
- John E Heffner, “Advance Care Planning in Chronic Obstructive Pulmonary Disease: Barriers and Opportunities,” Current Opinion in Pulmonary Medicine 17, no. 2 (2011): pp. 103-109.
- Carolien Burghout et al., “Benefits of Structured Advance Care Plan in End-of-Life Care Planning among Older Oncology Patients: A Retrospective Pilot Study,” Journal of Palliative Care 38, no. 1 (2022): pp. 30-40.
- K. M Detering et al., “The Impact of Advance Care Planning on End of Life Care in Elderly Patients: Randomised Controlled Trial,” BMJ 340, no. mar 23 1 (2010): pp. c1345-c1345.
- Rebecca Sudore et al., “Defining Advance Care Planning for Adults: A Consensus Definition from a Multidisciplinary Delphi Panel (S740),” Journal of Pain and Symptom Management 53, no. 2 (2017): pp. 431-432.
- Justin Porter et al., “Revisiting the Time Needed to Provide Adult Primary Care,” Journal of General Internal Medicine 38, no. 1 (January 2022): pp. 147-155.
- “Portable Medical Orders for Seriously Ill or Frail Individuals,” POLST (Louisiana Health Care Quality Forum, February 21, 2023).
- Burghout, Journal of Palliative Care, 2022.
- Detering, BMJ, 2010.
