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| ID | Type | Description | Link |
|---|---|---|---|
| 5K23AG070234-03 | U.S. NIH Grant/Contract | View source |
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| Name | Class |
|---|---|
| National Institute on Aging (NIA) | NIH |
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The purpose of this research is to examine the feasibility of using a patient portal based advance care planning (ACP) tool to improve ACP discussions and documentation in persons living with cognitive impairment in outpatient primary care.
The goal of this study is to explore whether sending a portal-based ACP tool (called ACPVoice) paired with a motivational message within the patient portal before a routine primary care physician visit can improve ACP discussions and documentation within the electronic health record among persons living with cognitive impairment in outpatient primary care.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| ACPVoice Intervention | Experimental | Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health , have a primary care physician at one of the participating sites, and have an active patient portal account. |
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| Standard of Care | Active Comparator | Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health, have a primary care physician within the Atrium-Wake Forest Baptist Health Network, and have an active patient portal account. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Advance Care Planning Tool - ACPVoice | Behavioral | Eligible patients will be sent a secure MyChart message with a motivational message asking them to complete the advance care planning tool (ACPVoice) with their care partner/surrogate decision-maker or loved one before their upcoming primary care visit. The ACPVoice tool will be attached electronically to the mychart message. A reminder message will be sent to an non-responders with a different motivational message. |
| Measure | Description | Time Frame |
|---|---|---|
| Reach/Engagement | Percentage of participants who open the advance care planning tool (ACPVoice) mychart message | 6 months post intervention |
| Intervention Completion | Percentage of participants who were sent the ACPVoice mychart message that complete the ACPVoice tool. | 6 months post intervention |
| Measure | Description | Time Frame |
|---|---|---|
| Advance Care Planning Documentation Rates by Primary Care Providers | Documentation of advance care planning within the electronic health record by primary care provider. | 12 months pre intervention |
| Advance Care Planning Documentation Rates by Primary Care Providers |
| Measure | Description | Time Frame |
|---|---|---|
| Barrier to Adoption | Data will be collected via qualitative interviews with participants and providers. | 6 months during the implementation period and up to 6 months post the implementation period |
| Quality of Advance Care Planning Documentation |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Jennifer Gabbard, MD | Wake Forest University Health Sciences | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Wake Forest University Health Sciences | Winston-Salem | North Carolina | 27157 | United States |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| ICF | No | No | Yes | Informed Consent Form | May 21, 2025 | Feb 25, 2026 |
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| Standard of Care for Advance Care Planning | Behavioral | Patients will have access to the standardized advance care planning questionnaires readily available already within their mychart account which is part of standard of care. |
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Documentation of advance care planning within the electronic health record by primary care provider. |
| 6 months post intervention |
| Advance Care Planning Billing Code Usage | Advance care planning billing codes usages will be recorded. | 12 months pre intervention |
| Advance Care Planning Billing Code Usage | Advance care planning billing codes usages will be recorded. | 6 months post intervention |
| Documented Designated Surrogate Decision Maker | Measured by number of designated surrogate decision makers documented in the electronic health record. | 12 months pre intervention |
| Documented Designated Surrogate Decision Maker | Measured by number of designated surrogate decision makers documented in the electronic health record. | 6 months post intervention |
High-quality advance care planning documentation will be defined as addressing ≥4 of the 8 core components with 1 point assigned for each of the following questions related to: health-related goals, what matters most/most important in their life, health-related worries/concerns, named surrogate decision-maker, how much information they would like to know, unacceptable states at the end-of-life, goals if their health was to worsen, and questions about advance care planning forms. Score of 0-8 with 0 indicating no advance care planning questions answered to 8 indicating eight core advance care planning questions answered.
| 6 months during the implementation period and up to 6 months post the implementation period |
| Participant Confidence related to PCP knowing what is important to them | Data will be collected via a RedCap survey asking 5 questions: i. How confident are you your primary care clinician/team knows what is important to you?, ii. How confident are you that what is important to you will determine the medical care you receive in the future? , iii. To what extent did completing this care planning tool increase or decrease your sense of control over medical decisions?, iv. Before completing the care planning tool, did your primary care clinician/team ask what is important to you? , and v. After completing the care planning tool, did your primary care clinician/team ask what is important to you? . | 6 months during the implementation period and up to 6 months post the implementation period |
| Feeling Heard and Understood | Data will be assessed via a RedCap survey with 4 questions: I felt heard and understood by this provider and team, I felt this provider and team put my best interests first when making recommendations about my care, I felt this provider and team saw me as a person, not just someone with a medical problem, I felt this provider and team understood what is important to me in my life. | 6 months during the implementation period and up to 6 months post the implementation period |
| Digital Health Literacy | Data will be measured using the Brief Digital Health Care Literacy Scale. | 6 months during the implementation period and up to 6 months post the implementation period |
| Telephone Advance Care Planning Completion Rates | Defined as the number of patients who complete the advance care planning tool (ACPVoice) over the telephone. | 6 months during the implementation period and up to 6 months post the implementation period |
| Paper Advance Care Planning Documentation Rates | Defined as the number of patients who were mailed and completed the advance care planning tool (ACPVoice) via mail. | 6 months during the implementation period and up to 6 months post the implementation period |
| Preference-concordant care | Data will be collected via Redcap survey asking "How strongly do you agree or disagree that your current medical/treatment plan meets your preferences". | 6 months during the implementation period and up to 6 months post the implementation period |
| Provider Survey Score | 17 multiple choice items regarding provider opinion on the interventions acceptability, appropriateness, feasibility and overall satisfaction. Total score range is 17-84 with a higher score indicating a more favorable opinion of the intervention. | 6 months post implementation period |
| ICF_000.pdf |
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| Release Date | Unrelease Date | Unrelease Date Unknown | Reset Date | MCP Release Number |
|---|---|---|---|---|
| Jun 16, 2026 |
| ID | Term |
|---|---|
| D060825 | Cognitive Dysfunction |
| D003704 | Dementia |
| ID | Term |
|---|---|
| D003072 | Cognition Disorders |
| D019965 | Neurocognitive Disorders |
| D001523 | Mental Disorders |
| D001927 | Brain Diseases |
| D002493 | Central Nervous System Diseases |
| D009422 | Nervous System Diseases |
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| ID | Term |
|---|---|
| D059039 | Standard of Care |
| D032722 | Advance Care Planning |
| ID | Term |
|---|---|
| D019984 | Quality Indicators, Health Care |
| D011787 | Quality of Health Care |
| D006298 | Health Services Administration |
| D017530 | Health Care Quality, Access, and Evaluation |
| D010347 | Patient Care Planning |
| D003191 | Comprehensive Health Care |
| D010346 | Patient Care Management |
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