Kim Jungyoon, Pacino Valerie, Koll Thuy, Mickles Maria S, Potter Jane F, Ma Jihyun, Estabrooks Paul
Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, USA.
Broadview Planning, LLC, San Juan, California, USA.
J Am Geriatr Soc. 2025 Aug;73(8):2553-2561. doi: 10.1111/jgs.19478. Epub 2025 Apr 16.
Despite the benefits of discussing patients' preferences on care decisions, the uptake of advance care planning (ACP) in the U.S. is low. This study aimed to (1) identify barriers to ACP implementation, (2) implement two strategies (onsite ACP coordinator and Lightning Report facilitation-a rapid process improvement involving prompt feedback synthesis and timely action), and (3) track ACP outcomes (reach, implementation, and effectiveness).
This study took place at two primary care sites participating in the Nebraska Geriatric Workforce Enhancement Program from 2020 to 2023. We conducted a multi-stage evaluation mixed-methods study guided by the Practical, Robust Implementation and Sustainability Model (PRISM). Qualitative data from clinic staff interviews and focus groups were collected to identify implementation barriers, develop an optimal workflow, and educate providers and patients (implementation). Quantitative data from electronic medical records (EMR) were collected at baseline and every six months thereafter to assess ACP outcomes, including reach (patient-provider discussion of ACP) and effectiveness (ACP document completion). We mapped barriers to implementation strategies, mechanisms, and ACP outcomes based on PRISM domains.
From 2019 to 2021, ACP outcomes remained consistent: Clinic A (reach: data not available; effectiveness: 20.5%-20.2%) and Clinic B (reach: 2.3%-2.6%; effectiveness: 1.8%-1.9%). After implementing the ACP coordinator and Lightning Report in 2022, moderate-to-high improvements were observed: Clinic A saw a 10-percentage point increase in reach (43.6%-53.6%) and a 2.5 increase in effectiveness (20.2%-22.8%). Clinic B experienced a significant 25.3-percentage point increase in reach (2.6%-27.9%) and a 16.5 increase in effectiveness (1.9%-18.4%). We also updated the clinic workflow to integrate the ACP initiative into standard practice (implementation).
The introduction of an ACP coordinator, along with the Lightning Report approach, may enhance ACP reach, effectiveness, and implementation in primary care settings for older patients.
尽管讨论患者对医疗决策的偏好有诸多益处，但美国的提前护理计划（ACP）实施率较低。本研究旨在：（1）确定 ACP 实施的障碍；（2）实施两种策略（现场 ACP 协调员和闪电报告促进——一种涉及及时反馈综合和及时行动的快速流程改进）；（3）跟踪 ACP 结果（覆盖面、实施情况和有效性）。
本研究在两个参与内布拉斯加老年劳动力增强计划的基层医疗点进行，时间为 2020 年至 2023 年。我们开展了一项由实用、稳健实施和可持续性模型（PRISM）指导的多阶段评估混合方法研究。收集来自诊所工作人员访谈和焦点小组的定性数据，以确定实施障碍、制定最佳工作流程，并对医护人员和患者进行教育（实施过程）。从电子病历（EMR）中收集基线数据以及此后每六个月的定量数据，以评估 ACP 结果，包括覆盖面（患者与医护人员对 ACP 的讨论）和有效性（ACP 文件完成情况）。我们根据 PRISM 领域将障碍映射到实施策略、机制和 ACP 结果。
2019 年至 2021 年，ACP 结果保持稳定：诊所 A（覆盖面：数据不可用；有效性：20.5% - 20.2%）和诊所 B（覆盖面：2.3% - 2.6%；有效性：1.8% - 1.9%）。2022 年实施 ACP 协调员和闪电报告后，观察到中度到高度的改善：诊所 A 的覆盖面提高了 10 个百分点（43.6% - 53.6%），有效性提高了 2.5 个百分点（20.2% - 22.8%）。诊所 B 的覆盖面显著提高了 25.3 个百分点（2.6% - 27.9%），有效性提高了 16.5 个百分点（1.9% - 18.4%）。我们还更新了诊所工作流程，将 ACP 倡议纳入标准实践（实施过程）。
引入 ACP 协调员以及闪电报告方法，可能会提高老年患者基层医疗环境中 ACP 的覆盖面、有效性和实施情况。
