Nurse Navigation Increases Advance Care Planning


Nurse navigation – in addition to a better EHR system – increased the percentage of older patients who utilized advance care planning.

Nurse navigator-led interventions led to more advanced care planning for vulnerable older adults, compared to standard of care, according to recent research published in JAMA Internal Medicine.

“Prior studies have highlighted that barriers to ACP for primary care professionals are related to uncertainty regarding when to discuss ACP, insufficient time, limited understanding of how to properly discuss ACP, and inability to bill for ACP,” the authors wrote.

The researchers sought out to determine if nurse navigator-led advanced care planning (ACP), coupled with a health care professional-facing electronic health record (EHR) interface increased how often advance care directives were documented in the EHR.

The EHR interface, ACPWise, provided standardized documentation with structured data elements, as well as a space for free-text comments. The researchers said that ACPWise also helped serve as a conversation guide for talking to patients about advance care.

“This study shows that some progress in combating these barriers can be made by expanding the team that guides ACP (nurse navigators), linking this team-based process to the Medicare annual wellness visit, and creating an EHR documentation interface to facilitate the workflow.”

A total of 759 patients from 8 primary care practices in North Carolina were involved in the study. They were all aged 65 or older; had multiple morbidities; had either cognitive or physical impairments and/or frailty. In the study population, 204 patients had a malignant tumor and 18 had metastatic disease.

Three-hundred, eighty were randomized to receive usual care, while 379 were randomized to the nurse navigator-led ACP pathway.

Ultimately, the group with the nurse-led intervention had a much higher percentage of ACP documentation than the group given usual care, 42.2% versus 3.7%, respectively. Additionally, the nurse-led group had a higher percentage of billing for ACP planning (25.3% versus 1.3%).

The group of patients that worked with the nurse navigators also had a higher percentage of assigning designated decision makers (64% versus 35%) and more frequently completed ACP legal forms (24.3% versus 10%), such as advance directives, living wills, or power of attorney, which were all uploaded into the EHR.

Interestingly, 26% of participants wanted only to discuss ACP with their nurse navigators, and did not want to have those conversations with their primary care providers.

“A nurse navigator-led ACP pathway integrated with a health care professional-facing HER interface substantially increases ACP discussion and documentation within the EHR,” the researchers wrote. “This trial suggests a promising new approach to ACP in the outpatient primary care setting and a potentially scalable approach to ACP for vulnerable older adults.”


Gabbard, Pajewski NM, Callahan KE, et. al. Effectiveness of a Nurse-Led Multidisciplinary Intervention vs Usual Care on Advance Care Planning for Vulnerable Older Adults in an Accountable Care Organization. JAMA Internal Medicine. doi:10.1001/jamainternmed.2020.5950 Published online January 11, 2021. Accessed Jan. 11, 2021.

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