Increasing Advance Care Planning in a Community Internal Medicine Clinic

Clinical Snapshot

Key Findings

• P Value: Overall χ²(3) = 24.74, P < 0.0001; all pairwise comparisons versus baseline P ≤ 0.005

• Effect Size: Absolute increase of 21.5 percentage points from baseline (2.5%) to final phase (24.0%); pre-specified target of 12.5% was exceeded at Phase 1 and substantially surpassed by Phase 3

• Primary Outcome: Documented ACP discussion during annual physicals increased from 2.5% at baseline to 12.2% (Phase 1: brochures), 17.1% (Phase 2: DotPhrase), and 24.0% (Phase 3: portal outreach) — a nearly tenfold increase from baseline to final phase

• Nnt Or Sensitivity: Not applicable (QI process improvement study). Advance directive upload rate increased from 1.7 to 6.0 per month (3.5-fold increase); ACP consult referrals increased from 0.0% to 10.9%; mean resident workflow burden score decreased from 4.9 to 3.0 (scale not specified)

• Confidence Interval: Not reported for any outcome measure

Clinical Application

The three interventions are low-cost and operationally feasible in most well-resourced ambulatory settings with EMR access. Nursing brochure distribution requires minimal training. DotPhrase or equivalent EMR prompting tools are available in most major EMR platforms (Epic, Cerner). Patient portal outreach requires administrative coordination but is increasingly standard. Adaptation to non-residency settings would require attention to continuity of care and role allocation. ACP is a recognised priority in Australian healthcare, supported by Advance Care Planning Australia (ACPA) and embedded in RACGP Standards for General Practice (5th Edition). Medicare Benefits Schedule (MBS) item 132 provides remuneration for ACP discussions in general practice (introduced 2022), creating a financial incentive aligned with this study's approach. The My Health Record system provides a national platform for advance care document upload, analogous to the EMR-based AD upload described here. TGA considerations are not directly relevant. The DotPhrase concept is replicable within Best Practice, Medical Director, and Epic environments used across Australian primary and tertiary care. Cultural considerations for First Nations patients and CALD communities require tailored ACP communication strategies beyond the scope of this study. The RACGP's 'Silver Book' and Palliative Care Australia guidelines support systematic ACP integration in primary care, reinforcing the clinical relevance of this QI approach to the Australian context. Adult patients attending ambulatory internal medicine clinics, particularly those without existing advance directives, presenting for annual health assessments. Most applicable to patients aged 65 and over, those with chronic illness, and those in settings with established EMR and patient portal infrastructure.

Abstract

INTRODUCTION: Advance care planning (ACP) supports goal-concordant care but remains underused nationally. In resident clinics, limited continuity, short visits, and lack of standardized workflows create barriers to ACP integration. In our Community Internal Medicine resident clinic, ACP discussion was documented in 2.5% of annual physicals, and 19.6% of paneled patients had an advance directive (AD) on file. We aimed to increase ACP documentation from 2.5% to 12.5% within 1 year without increasing perceived resident workflow burden. METHODS: We conducted a resident-led quality improvement project using Lean Six Sigma methodology. Three interventions were implemented sequentially: nursing distribution of ACP brochures, an electronic medical record DotPhrase to prompt and document ACP discussions, and targeted patient portal outreach to patients without an AD before annual visits. The primary outcome was documented ACP discussion during annual physicals. Secondary outcomes included AD uploads and ACP consult referrals. The balancing measure was resident-perceived workflow burden. Charts were reviewed over 5-week periods at baseline (n = 118) and after each implementation phase (n = 132, 158, 129). RESULTS: ACP documentation increased from 2.5% at baseline to 12.2%, 17.1%, and 24.0% across sequential phases (χ2(3) = 24.74, P < 0.0001). Pairwise comparisons versus baseline were significant (all P ≤ 0.005). AD upload rate increased from 1.7 to 6.0 per month, and ACP consult referrals increased from 0.0% to 10.9%. Mean perceived workflow burden decreased from 4.9 to 3.0. CONCLUSION: Workflow-embedded interventions improved ACP documentation, AD uploads, and ACP referrals without increasing perceived resident burden.

References

1. 1.Vattikonda, A., Ibrahim, M., Scott, D., Gansert, E., Phillipps, J., Chase, R. C., Madaffari, C., & Valery, J. R. (2025). Increasing advance care planning in a community internal medicine clinic. American Journal of Medical Quality: The Official Journal of the American College of Medical Quality. https://doi.org/10.1097/JMQ.0000000000000322