Trainee-Led Patient Education to Increase Advance Care Planning in a Geriatric Primary Care Clinic

BACKGROUND: Advance care planning (ACP) is critical for communicating patients' preferences for future medical care, especially in geriatric populations. Despite the acknowledged importance, completion rates remain low. OBJECTIVE: We aimed to increase ACP in a geriatric primary care clinic (geri-PCC) using a trainee-led educational intervention. DESIGN: Retrospective analysis of a quality improvement intervention. PARTICIPANTS: In total, 498 patients, > 60 years old with no advance directives (AD) or Portable Medical Orders (POLST) were seen in the geri-PCC during the intervention period. Sixty-five received the intervention while 433 did not. INTERVENTION: We incorporated an ACP education session led by medical trainees into the geri-PCC workflow 3/2023-4/2023. MAIN MEASURES: New AD (includes durable power of attorney for healthcare (dPOA) and Living Will (LW)) and POLST captured in the EMR, ICD-10 codes billed for ACP/goals of care (GOC) were compared between the intervention and standard care groups during 6 months following the intervention period. Secondary logistic regression analyses adjusted for age, gender, mood disorder, and cognitive impairment when evaluating the intervention's association with primary outcomes. KEY RESULTS: The intervention group had more new dPOA forms (13.8% vs 5.3%, p = 0.025) and ACP/GOC codes (32% vs 13%, p < 0.001). These findings remained significant after adjusting for age, gender, mood disorder, and cognitive impairment (dPOA OR = 2.96, 95% CI 1.24-6.59, p = 0.010; ACP/GOC OR 3.07, 95% CI 1.67-5.52, p < 0.001). Cognitive impairment was associated with more completion of POLST (OR = 3.29, 95% CI 1.15-11.0, p = 0.035) but less completion of LWs (OR = 0.34, 95% CI 0.13-0.79, p = 0.018). CONCLUSIONS: Incorporating an ACP education session led by medical trainees was associated with increased AD documentation in the EMR and increased ACP/GOC codes billed in our geri-PCC. The emergence of cognitive impairment as a predictor of POLST completion needs further exploration.

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Publication Details

Journal
Journal of General Internal Medicine
Published
2026-06-30
DOI
https://doi.org/10.1007/s11606-026-10585-2
Primary Topic
Palliative Care and End-of-Life Issues
Type
article
Field-Weighted Citation Impact
0.00

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article

Trainee-Led Patient Education to Increase Advance Care Planning in a Geriatric Primary Care Clinic

Zehra B. Omer, Z M Shakir, Archana Sadangi, Susan Dara et al.
Journal of General Internal Medicine
Palliative Care and End-of-Life Issues
article

Trainee-Led Patient Education to Increase Advance Care Planning in a Geriatric Primary Care Clinic

Zehra B. Omer, Z M Shakir, Archana Sadangi, Susan Dara, M V Parulekar, Simon Gelman, Sidrah Rafiq, Sakshi Jain
article en

Abstract

BACKGROUND: Advance care planning (ACP) is critical for communicating patients' preferences for future medical care, especially in geriatric populations. Despite the acknowledged importance, completion rates remain low. OBJECTIVE: We aimed to increase ACP in a geriatric primary care clinic (geri-PCC) using a trainee-led educational intervention. DESIGN: Retrospective analysis of a quality improvement intervention. PARTICIPANTS: In total, 498 patients, > 60 years old with no advance directives (AD) or Portable Medical Orders (POLST) were seen in the geri-PCC during the intervention period. Sixty-five received the intervention while 433 did not. INTERVENTION: We incorporated an ACP education session led by medical trainees into the geri-PCC workflow 3/2023-4/2023. MAIN MEASURES: New AD (includes durable power of attorney for healthcare (dPOA) and Living Will (LW)) and POLST captured in the EMR, ICD-10 codes billed for ACP/goals of care (GOC) were compared between the intervention and standard care groups during 6 months following the intervention period. Secondary logistic regression analyses adjusted for age, gender, mood disorder, and cognitive impairment when evaluating the intervention's association with primary outcomes. KEY RESULTS: The intervention group had more new dPOA forms (13.8% vs 5.3%, p = 0.025) and ACP/GOC codes (32% vs 13%, p < 0.001). These findings remained significant after adjusting for age, gender, mood disorder, and cognitive impairment (dPOA OR = 2.96, 95% CI 1.24-6.59, p = 0.010; ACP/GOC OR 3.07, 95% CI 1.67-5.52, p < 0.001). Cognitive impairment was associated with more completion of POLST (OR = 3.29, 95% CI 1.15-11.0, p = 0.035) but less completion of LWs (OR = 0.34, 95% CI 0.13-0.79, p = 0.018). CONCLUSIONS: Incorporating an ACP education session led by medical trainees was associated with increased AD documentation in the EMR and increased ACP/GOC codes billed in our geri-PCC. The emergence of cognitive impairment as a predictor of POLST completion needs further exploration.

Journal of General Internal Medicine
Hackensack University Medical Center (US), Hackensack Meridian Health (US), Center for Discovery (US)
Hackensack Meridian Health
Quality Education
Openalex Percentile: Top 7%
Palliative Care and End-of-Life Issues
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