Implementation and Impact of Patient Lay Navigator-Led Advance Care Planning Conversations.

Rocque GB1, Dionne-Odom JN2, Sylvia Huang CH3, Niranjan SJ4, Williams CP5, Jackson BE6, Halilova KI4, Kenzik KM5, Bevis KS7, Wallace AS8, Lisovicz N9, Taylor RA2, Pisu M6, Partridge EE4, Butler TW10, Briggs LA11, Kvale EA12; Patient Care Connect Group.

Abstract

CONTEXT:

Advance care planning (ACP) improves alignment between patient preferences for life-sustaining treatment and care received at end of life (EOL).

OBJECTIVES:

To evaluate implementation of lay navigator-led ACP.

METHODS:

A convergent, parallel mixed-methods design was used to evaluate implementation of navigator-led ACP across 12 cancer centers. Data collection included 1) electronic navigation records, 2) navigator surveys (n = 45), 3) claims-based patient outcomes (n = 820), and 4) semistructured navigator interviews (n = 26). Outcomes of interest included 1) the number of ACP conversations completed, 2) navigator self-efficacy, 3) patient resource utilization, hospice use, and chemotherapy at EOL, and 4) navigator-perceived barriers and facilitators to ACP.

RESULTS:

From June 1, 2014 to December 31, 2015, 50 navigators completed Respecting Choices® First Steps ACP Facilitator training. Navigators approached 18% of patients (1319/8704); 481 completed; 472 in process; 366 declined. Navigators were more likely to approach African American patients than Caucasian patients (20% vs. 14%, P < 0.001). Significant increases in ACP self-efficacy were observed after training. The mean score for feeling prepared to conduct ACP conversations increased from 5.6/10 to 7.5/10 (P < 0.001). In comparison with patients declining ACP participation (n = 171), decedents in their final 30 days of life who engaged in ACP (n = 437) had fewer hospitalizations (46% vs. 56%, P = 0.02). Key facilitators of successful implementation included physician buy-in, patient readiness, and prior ACP experience; barriers included space limitations, identifying the "right" time to start conversations, and personal discomfort discussing EOL.