Building a System-Wide Approach to Support Advance Care Planning Within an Academic Medical Center: Continuity Across Care Settings

J Gen Intern Med. 2026 May 1. doi: 10.1007/s11606-026-10269-x. Online ahead of print.

ABSTRACT

BACKGROUND: Advance care planning (ACP) is a vital tool to align patients’ goals and values with their medical care; however, ACP has low completion rates. Barriers to ACP include lack of continuity across care settings, consistent documentation, electronic health record (EHR) accessibility to ACP information, and need for clinician education. To address these barriers, system-wide healthcare initiatives are needed.

OBJECTIVES: Examine a health system-wide approach to improve ACP completion and continuity among adult patients within an academic medical center.

DESIGN: Retrospective cohort study PARTICIPANTS: A total of 34,268 patients aged 65 years or older receiving healthcare at a single academic medical center.

INTERVENTION: A multimodal initiative across care settings (ambulatory, transition of care, and emergency department/hospital) was implemented to include patient cohort identification, EHR enhancements, addition of ACP dedicated social workers to enhance continuity, and clinician education.

MAIN MEASURES: ACP completion was the primary outcome and defined as (1) completion of a Medical Orders for Life-Sustaining Treatment (MOLST) or Advance Healthcare Directive document, (2) identification of a surrogate decision maker, or (3) documentation of conversations regarding ACP goals.

KEY RESULTS: Fifty-one percent of the cohort completed ACP during the study (Feb. 2021-Jan. 2024). ACP completion likelihood increased among patients with a positive surprise question screen (adj IRR 4.56, [CI 3.52, 5.90]) and those diagnosed with dementia (adj IRR 1.59 [CI 1.47, 1.72]), advance cancer (adj IRR 1.37 [CI 1.19, 1.58], and heart failure (adj IRR 1.11 [Cl 1.04, 1.19]. Compared to baseline, ACP completion increased during both operational implementation periods: first period adj IRR 1.24 (CI 1.16, 1.32) and second period adj IRR 3.54 (CI 3.38, 3.70).

CONCLUSIONS: This multipronged approach to a system-wide ACP implemented across care settings at an academic medical center led to an increase in ACP completion and provides a framework for other academic medical centers.

PMID:42067743 | DOI:10.1007/s11606-026-10269-x