title: Implementation and Impact of Patient Lay Navigator-Led Advance Care Planning Conversations.
abstract: Advance care planning (ACP) improves alignment between patient preferences for life-sustaining treatment and care received at end of life (EOL).
  
  
  
  To evaluate implementation of lay navigator-led ACP.
  
  
  
  A convergent, parallel mixed-methods design was used to evaluate implementation of navigator-led ACP across 12 cancer centers. Data collection included 1) electronic navigation records, 2) navigator surveys (n = 45), 3) claims-based patient outcomes (n = 820), and 4) semistructured navigator interviews (n = 26). Outcomes of interest included 1) the number of ACP conversations completed, 2) navigator self-efficacy, 3) patient resource utilization, hospice use, and chemotherapy at EOL, and 4) navigator-perceived barriers and facilitators to ACP.
  
  
  
  From June 1, 2014 to December 31, 2015, 50 navigators completed Respecting Choices®First Steps ACP Facilitator training. Navigators approached 18% of patients (1319/8704); 481 completed; 472 in process; 366 declined. Navigators were more likely to approach African American patients than Caucasian patients (20% vs. 14%, P < 0.001). Significant increases in ACP self-efficacy were observed after training. The mean score for feeling prepared to conduct ACP conversations increased from 5.6/10 to 7.5/10 (P < 0.001). In comparison with patients declining ACP participation (n = 171), decedents in their final 30 days of life who engaged in ACP (n = 437) had fewer hospitalizations (46% vs. 56%, P = 0.02). Key facilitators of successful implementation included physician buy-in, patient readiness, and prior ACP experience; barriers included space limitations, identifying the "right" time to start conversations, and personal discomfort discussing EOL.
  
  
  
  A navigator-led ACP program was feasible and may be associated with lower rates of resource utilization near EOL.
authors.affiliation: Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA. Electronic address: grocque@uabmc.edu.
authors.forename: Gabrielle B
authors.initials: GB
authors.lastname: Rocque
authors.affiliation: School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: J Nicholas
authors.initials: JN
authors.lastname: Dionne-Odom
authors.affiliation: Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Chao-Hui
authors.initials: CH
authors.lastname: Sylvia Huang
authors.affiliation: Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Soumya J
authors.initials: SJ
authors.lastname: Niranjan
authors.affiliation: Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Courtney P
authors.initials: CP
authors.lastname: Williams
authors.affiliation: Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Bradford E
authors.initials: BE
authors.lastname: Jackson
authors.affiliation: Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Karina I
authors.initials: KI
authors.lastname: Halilova
authors.affiliation: Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Kelly M
authors.initials: KM
authors.lastname: Kenzik
authors.affiliation: Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Kerri S
authors.initials: KS
authors.lastname: Bevis
authors.affiliation: Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Audrey S
authors.initials: AS
authors.lastname: Wallace
authors.affiliation: Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Nedra
authors.initials: N
authors.lastname: Lisovicz
authors.affiliation: School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Taylor
authors.affiliation: Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Maria
authors.initials: M
authors.lastname: Pisu
authors.affiliation: Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Edward E
authors.initials: EE
authors.lastname: Partridge
authors.affiliation: University of South Alabama Mitchell Cancer Institute, Mobile, Alabama, USA.
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Butler
authors.affiliation: Gundersen Health System, La Crosse, Wisconsin, USA.
authors.forename: Linda A
authors.initials: LA
authors.lastname: Briggs
authors.affiliation: Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Kvale
mesh_terms: D032722:Advance Care Planning; D000368:Aged; D000970:Antineoplastic Agents / Q000627:therapeutic use; D003142:Communication; D004501:Education, Medical; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006282:Health Personnel / Q000193:education / Q000523:psychology; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D009369:Neoplasms / Q000453:epidemiology / Q000628:therapy; D062526:Patient Navigation; D057240:Patient Preference; D036301:Qualitative Research; D020377:Self Efficacy; D011795:Surveys and Questionnaires; D013727:Terminal Care / Q000706:statistics & numerical data
chemical_list: D000970:Antineoplastic Agents
keywords: Advance care planning; end of life; lay navigation; lay navigator