Integrated Multidisciplinary Patient and Family Advance Care Planning Trial

Integrated Approach to Patient and Family Engagement for Advance Care Planning for Vulnerable Older Adult Within an Accountable Care Organization (ACO)

The purpose of this study is to compare ways to engage sick patients and their family members in Advance Care Planning (ACP) discussions. Two pathways will be tested, discussions using a Nurse Navigator led pathway versus usual care.

This study is a randomized, pragmatic, comparative effectiveness trial for determining better ways to engage multimorbid patients and their family members in Advance Care Planning through a Nurse Navigator led pathway versus usual care. Investigators propose to utilize Zelen's design (a more recent label/generalization for this type of design is the cohort multiple randomized controlled trial (cmRCT), a pragmatic clinical trial design whereby all participants are randomized prior to informed consent, and then only patients randomized to the interventional arm are approached for consent and subsequently enrolled in the intervention group.

Inclusion Criteria:

• Aged 65 or older patient within the Wake Forest/Cornerstone ACO
• Have seen their primary care provider within the Wake Forest/Cornerstone network in the past 12 months
• English speaking
• No documented Advance Directive in the EHR
• Impairments in either physical function, cognition, and/or frailty

Exclusion Criteria:

• No available proxy (e.g. in setting of cognitive impairment)
• Severe/advanced dementia
• Moderate to severe hearing loss
• Non-English speaking
• No phone number available for patient