Advanced Care Planning Initiative in Outpatient Geriatric & Palliative Care

Topic: Advance Care Planning Initiatives

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In January 2016, the Centers for Medicare and Medicaid Services (CMS) began reimbursement for advance care planning (ACP) conversations with patients. These conversations are a means for patients, together with physicians and families, to establish goals of care (GOC) for their future. Although it is especially important to conduct and document ACP conversations with seriously ill and/or frail elderly patients, studies have shown patients prefer their physician to initiate these conversations. Outpatient offices provide an ideal setting to address ACP and hold ACP conversations to allow patients to establish GOC before a health event or crisis, rather than in the ED or ICU during a crisis.


ACP discussions can take a few minutes or can be extensive, including a discussion of GOC, advanced directives and/or filling out Medical Orders for Life Sustaining Treatment (MOLST) forms. These discussions may be billable if provided face to face with patient and/or family in a 30 minute or greater time frame. In a usual routine visit, an ACP discussion is typically not performed, or performed but not documented in a designated area in the electronic medical record (EMR), making the discussed information inaccessible to other healthcare providers.


Our goal is to improve outpatient ACP discussions and documentation. We also look to educate providers and learners about the importance of these discussions and ensure proper, consistent, documentation is in the chart.

This project was held in the outpatient faculty practice of the Northwell Health Geriatric and Palliative Medicine physicians. It is a multi-disciplinary office with 7 Attending Geriatric and/or Palliative physicians. 5 Geriatric Fellows; internal medicine residents, 1 social worker; 1 PharmD; pharmacy students; Geriatric certified Nurses; office manager see in approximately 4445 patient visits annually.

QI Project Methodology:

This program began in July 2016 with collaboration from the Institute of Healthcare Improvement. As part of the comprehensive assessment, each patient is provided information about health care proxies (HCP), MOLST forms, and/or goals of care. Our team assists with completion of HCP or MOLST, if applicable, forms in office. There is then documentation of ACP preferences in a specifically identified area of the patient’s chart in the EMR, which is readily visible to outside providers. A social worker is available to help the patients and providers. The office staff then scan completed forms into the patient’s chart. Each week, an office staff nurse audits two charts/provider/week (56/month) to see if ACP have been addressed. The data is then reviewed with the providers at the monthly faculty meetings. Upon review with the providers at the faculty meeting, barriers are identified and solutions are discussed and shared.


Some identified barriers include having the time to screen for ACP, having ACP decisions completed in different health settings, but not shared (i.e. in an inpatient setting or sub-acute rehabilitation center), and having different EMR systems used throughout the healthcare continuum (inpatient, outpatient, skilled nursing facility). Despite the push by CMS and the team support, providers struggle to accomplish 100% documentation of ACP wishes.


Some suggested solutions discussed over time include the need to ensure that the MOA completes the pre-visit checklist prior to a patient’s arrival, including highlighting the ACP section if not completed. This is often accomplished with the assistance of education and reinforcement by office manager. Furthermore, providers are educating residents/fellows on the importance of ACP discussions.


Through this quality improvement project there has been an increase in ACP discussions and documentation. At the start of the project there were 31.5 of the 56 charts (56.3%) had ACP documentation. Within 6 months that rate had increased to 40.6 of the 56 charts (72.5%). And after 3 more months, it increased to 51 of 56 charts (91%).


Through comprehensive evaluation of office processes and identification of barriers and possible solutions we were able to demonstrate significant improvement on ACP discussion and documentation in an outpatient office setting.



  • Doreen Devins, RN
  • Kathleen Busardo, RN
  • Kinga Kiszko, DO
  • Maria Carney, MD
  • Rupal Shah, MD

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