Doctor of Nursing Practice
Adult Gerontological Primary Care Nurse Practitioner (AGPCNP)
Year Degree Awarded
Month Degree Awarded
advance directive, advance care planning, primary care, intervention
Dr. Jeungok Choi
DNP Project Chair
Dr. Jeungok Choi, RN, PhD, MPH
DNP Project Outside Member Name
Dr. Cecilia Vicuna-Keady, FNP, ARNP
Background: Advance care planning (ACP) is a process to support patients in understanding and expressing their future medical wishes. Despite evidence supporting the benefits of ACP there remain a number of barriers limiting uptake of this important practice. Absence of advance care planning places patients at risk of receiving care misaligned with their values, goals, and preferences as well as increased patient and family distress at end-of-life. Purpose: This quality improvement (QI) project addressed provider knowledge, and patient awareness and level of engagement in the advance care planning process in an effort to increase the frequency and efficacy of ACP within a primary care setting. Methods: Under the framework of the Transtheoretical Model this QI project implemented three synergistic interventions. A staff education session included a PowerPoint presentation and introduction of the PREPARE website, an interactive ACP decision tool. The practice intervention included adults 30 and older scheduled for annual physical or Medicare wellness visits within a New England family practice. Emailed invitations advised patients ACP would be discussed at their upcoming appointments. During the visits ACP was explained and patients were introduced to the PREPARE tool. Measurable outcomes included percentage of staff participation in educational intervention, number of encounters with ACP billing codes, and mean score of the 9-item Advanced Care Planning Engagement Survey (ACPES). Number of ACP billing codes were measured three months pre/post intervention. Pre/post intervention mean ACPES scores were analyzed with a paired t test. Results:50 patient participants took part, 20 completed the post intervention ACPES. No change in frequency of ACP billing codes was noted. There was statistical significance that interventions increased patient ACPES scores (paired t(19)=2.09, p=.02, with pre intervention mean score of 3.66 (SD=0.94), followed by post intervention mean score of 4.08 (SD=0.68). Conclusion: A multilevel approach to address ACP barriers has been found to improve patient engagement in ACP. Future interventions should continue to build upon methods of staff and patient education as well as seek to improve systems level barriers.
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