JMIR Publications

ABSTRACT

Background:

Many of the challenges in Advanced Care Planning (ACP) conversations are linked to the waxing and waning progress of serious illnesses. The first challenge is in identifying appropriate patients in order to not waste medical resources or patients’ time. The second challenge is in recruiting patients to spend time now on these conversations; this includes meeting their current needs and concerns.

Objective:

The objective of our tSICC program was to successfully recruit Veterans who have not completed formal advance care planning to engage in these conversations by addressing the Veteran’s current needs and concerns.

Methods:

The protocol outlined herein utilizes administrative data to determine those patients who have not completed formal ACP documentation in the health system electronic health record and who are at above average risk for death in the next 3 to 5 years. The highlights of the tSICC protocol include addressing current patient concerns while focusing on future medical decision making.

Results:

As of September 2022, 196 Veterans completed this intervention. The timing of the protocol is patient driven, and the patient and their primary healthcare team decide what are the next steps, including completing and submitting formal ACP paperwork.

Conclusions:

This recruitment protocol has been successful in recruiting patients to engage in the conversation, as well as resulting in an increase in completed formal documentation for this population.