Incorporating Advance Care Planning Discussions into Annual Wellness Exams

Abstract

Background: Advance care planning, a part of the Medical Orders for Life-Sustaining Treatment (MOLST) form and Advance Directives (ADs), is an important discussion that older adults may use to review and record their goals of care in the event of incapacitation or inability to communicate. Conducting regular advance care planning discussions with older adults can help avoid unnecessary hospitalizations and high healthcare costs. However, there is a lack of advance care planning regulation in independent living centers, which creates inconsistencies between documents and patients’ wishes.

Local Problem: The nurse practitioner at an urban continuing care retirement community identified advance care planning as a priority that required a quality improvement project in the independent living facility’s ambulatory care center. A formal audit of resident charts had not been conducted to evaluate completion of advance care planning forms and whether resident preferences matched between MOLSTs and ADs. There was also a lack of a systematic approach to ensure advance care planning discussions were occurring at regular intervals. The purpose of the quality improvement project was to audit charts for MOLST and AD discrepancies and to implement a systematic approach to prompt discussions about patients’ preferences for care.

Interventions: Prior to the intervention, a chart audit comparing independent living facility residents’ MOLSTs and ADs was performed over four weeks to assess for inconsistencies in goals of care such as desire for transfer to the hospital, placement and use of feeding tubes, and intravenous therapy. After the audit, the 10-week implementation phase occurred, consisting of a systematic approach to implementing advance care planning discussions during scheduled Medicare annual wellness visit. The advance care planning discussions helped determine if any preferences had changed and required a MOLST or Advance Directive documentation change.

Results: A total of 174 residents’ charts were reviewed. Of the 61 residents who had both a MOLST and AD in the chart, two of those residents had a discrepancy regarding artificial hydration and nutrition. There was a total of eight Medicare annual wellness visits – all residents had an advance care planning discussion but no resident desired a change to the plan of care that required a MOLST change. Unintended results showed that 15 residents were missing MOLSTs, 12 residents had different paper and electronic MOLSTs, and 24 residents had MOLSTs that were voided incorrectly in various ways including not voiding the old MOLST or only voiding one page of the old MOLST.

Conclusions: Advance care planning is a valuable discussion to not only decrease hospitalizations and health care costs, but to improve quality of life for older adults. Audits can be instrumental in discovering discrepancies in patient preferences and workflow issues. This can help staff identify ways to fix MOLST tracking processes and to sustain routine advance care planning discussions. Though hospitalization rates were unable to be determined during the short implementation period, systematic processes can provide a basis for consistent advance care planning discussions to assess patient preferences in independent living facilities.