Group Visits for Advance Care Planning Among Older Adults with Heart Failure

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Background: Early advance care planning (ACP) is critical for older adults with heart failure (HF), who face an uncertain trajectory marked by increasingly complex treatment decisions. HF is highly prevalent among the elderly, who typically have a high burden of comorbidity that further complicates the disease trajectory, with implications for the use of life- prolonging interventions. Our approach to ACP has recently shifted from a narrow focus on advance directives to helping patients identify and communicate their broad healthcare values early in the illness trajectory to prepare them for in-the- moment decision making. Unfortunately, the time, skills, and resources required for patient-provider discussions about values clarification often results in delayed or overlooked ACP communication. A group visit approach to values clarification offers economies of scale while also leveraging aspects of social learning to enhance patient engagement in ACP and values clarification. Although group visits have been effectively used in chronic disease management, this model has not yet been applied to the ACP-values clarification context. Purpose: To establish the acceptability, feasibility and preliminary impact of using group visits for ACP focused on values clarification among elderly HF patients and their surrogates in preparation for a planned R01 trial. Specific Aims (1) Refine an ACP-HF group visit intervention based on input from older HF patients, their surrogates, and their primary providers; and (2) Evaluate the acceptability, feasibility and preliminary impact on ACP-relevant outcomes of the ACP-HF group visit intervention among older HF patients, their surrogates, and their primary providers. Research Design/Methods: This is a mixed-methods study of an ACP-HF group visit intervention focused on values clarification. In Aim 1, we will conduct 3 prototype ACP-HF group visits and 2 follow-up group visits and then conduct cognitive interviews and administer brief surveys to elicit focused feedback from participants. We will use surveys to elicit feedback from the patient participants' primary providers on a prototype group visit summary note to tailor the communication between the group visit intervention and the clinical setting. We will use these data to refine the conduct and curriculum of the prototype intervention in preparation for pilot-testing. In Aim 2, we will pilot 6 ACP-HF group visits and 2 follow-up group visits and assess the acceptability, feasibility, and preliminary impact on ACP-relevant outcomes of the visits through pre-post survey evaluations, semi-structured interviews, structured observations of the group visits, and exploratory statistical analyses. We will also collect feedback from primary providers on the perceived utility and quality of the information provided to them about their patients' participation in the group visits. Implications: Findings from this study will provide the methodological and logistical foundation for a planned R01 trial to evaluate the effectiveness of an ACP-HF group visit intervention. This study will also advance our understanding of how to efficiently incorporate the complex and time-consuming process of values clarification into clinical practice through the use of group visits.