A Telehealth Advance Care Planning Intervention for COVID-19 in New York City

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The novel Coronavirus Disease 2019 (COVID-19) has highlighted the importance of advance care planning (ACP) for older patients who are most at risk of dying, and a critical need exists to optimize this process. ACP empowers patients to express their values and goals for care before they become too ill to do so. ACP also prepares patients, and their families, to make difficult decisions in real time when the moment arises. For older patients, COVID-19 may result in respiratory failure and high mortality rates. However, many older patients may prefer to avoid these interventions, especially if the mortality rate is high and death is experienced alone in the hospital without family nearby. Motivated by the disproportionate risk to older patients from COVID-19 and the higher mortality rates, primary care clinicians should engage all older patients with ACP to ensure their preferences are known and honored. Unfortunately, many clinicians have not been trained in ACP and patients are unfamiliar with it. To address this gap, we have developed a Comprehensive Telehealth ACP Program for COVID-19 that implements ACP routinely into medical care and responds to the present need for virtual communication. The ACP Program combines two well-tested, evidence-based, and complementary interventions: online clinician communication skills training and ACP patient video decision aids. The overall objective of this application is to reduce the burden of COVID-19 and its consequences for an aging US population that may prefer to forgo aggressive potentially ineffective interventions, and to die outside of the hospital setting. To accomplish this, we propose to conduct a Pre-Post trial using an open cohort design of a telehealth ACP Program among older patients in the nation's COVID-19 epicenter, New York. We will train 250 primary care clinicians caring for 25,000 diverse patients over the age of 65 from the largest health care system in New York (Northwell Health). We will use Natural Language Processing to abstract our outcomes from the electronic health records for patients. We hypothesize that a telehealth ACP Program of clinician serious illness communication skills training combined with ACP videos will improve and sustain rates of ACP from the time that the intervention is implemented compared to the time prior to the intervention. Clinician communication training and video decision support is a practical, evidence-based, and innovative approach to uniformly provide robust ACP. Major strengths of this proposal are: the highly experienced team making this project feasible; the present infrastructure already embedded at Northwell Health, which has the largest number of COVID-19 patients in the US; and, the potential immediate deployment of the intervention, if successful, across the country. This work holds the promise of improving the quality of care provided to millions of Americans during the COVID-19 pandemic.