title: Disease specific advance care planning for heart failure patients: implementation in a large health system.
abstract: OBJECTIVE
  This study evaluates the implementation of Disease Specific Advance Care Planning (DS-ACP) for heart failure patients in a large health care system. The DS-ACP model uses a trained facilitator to guide communication between patient and proxy regarding patient values and goals for treatment in worst-case scenarios, develop a disease specific documentation plan, and identify needed resources.
  
  
  METHODS
  Referral and DS-ACP service delivery data were merged with electronic health record data. Process measures for implementation are described. Patients who participated in DS-ACP are compared with those who did not on demographics, medical characteristics, and outcomes such as inpatient readmissions, and hospice use among those who died. A chart audit was completed on a sample of patients to examine differences in advance care planning documentation between participants and nonparticipants.
  
  
  RESULTS
  Nearly one third (31.8%) of the 1894 heart failure patients referred to DS-ACP participated. Referral method was associated with participation. A chart audit revealed 94.3% of those completing the DS-ACP process, had a health directive compared to 24.8% of noncompleters (p<0.001). Of the patients who died by the end of the study period (n=286), DS-ACP participants were more likely to have used hospice compared to nonparticipants (56% versus 37%, p=0.002).
  
  
  CONCLUSIONS
  These initial evaluation results indicate the DS-ACP model, previously tested in randomized trials, can be successfully implemented among heart failure patients in a large health care system. Results demonstrate the importance of referral method and show initial positive results for participation, improved documentation, and hospice use.
authors.affiliation: Advance Care Planning, Allina Hospitals and Clinics, Minneapolis, Minnesota, USA.
authors.forename: Sandra
authors.initials: S
authors.lastname: Schellinger
authors.forename: Abbey
authors.initials: A
authors.lastname: Sidebottom
authors.forename: Linda
authors.initials: L
authors.lastname: Briggs
mesh_terms: D032722:Advance Care Planning / Q000458:organization & administration* / Q000592:standards; D000368:Aged; D002908:Chronic Disease; D015897:Comorbidity; D057286:Electronic Health Records; D005260:Female; D006333:Heart Failure; D017051:Hospice Care / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D015397:Program Evaluation; D014922:Wisconsin