Using Nurse Care Managers Trained in the Serious Illness Conversation Guide to Increase Goals-of-Care Conversations in an Accountable Care Organization.

Community-dwelling adults with serious illness benefit from conversations about their goals for care. We undertook a project to increase the number of serious illness conversations occurring in an accountable care organization (ACO) using a script delivered telephonically by nurse care managers. Working with nurses previously trained in the basics of geriatric assessment and goals-of-care conversations, we used a quality improvement framework to modify the Ariadne Laboratories Serious Illness Conversation Guide to a six-question script. Our target population was a subset of patients enrolled in a program within the ACO for patients who are high health care utilizers. After testing and modifying the script, we imbedded it into the initial nursing assessment in the electronic medical record. The electronic medical record prompts the nurses to ask the questions every three months to track changes in goals of care over time. We have increased documentation of goals-of-care conversations from 33% of patients in the subpopulation during the first month of this project to 86% at the end of the first year. Nurse care managers' report that clinical outcomes are improved by these conversations. This project demonstrates a unique way to modify the Serious Illness Conversation Guide for use by nurses as part of a health care team. This project can be adapted by other health care organizations trying to increase goals-of-care conversations in their patient population.