Using the Electronic Health Record to Identify and Promote Goals-of-Care Communication for Older Patients with Serious Illness

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Although discussions that address patients' goals of care are one of the most important aspects of palliative care, this communication is often lacking in our healthcare system. Goals-of-care communication is associated with improved patient and family outcomes and reduced intensity of care at the end of life. Electronic health records (EHR) provide a key opportunity to identify patients who would benefit from these discussions and to promote these discussions, yet prior interventions have not used the EHR for this purpose. Older adults with chronic illness, and particularly those with Alzheimer's disease and related dementias (ADRD), are especially vulnerable to inappropriately intensive end-of-life care. To address this shortcoming, we build on two of our most successful programs, one using the EHR to identify goals-of-care discussions and the other a novel intervention called Jumpstart that promotes and enhances these discussions. We will examine the effectiveness of the Jumpstart intervention for hospitalized older adults with chronic illness and specifically oversample those with ADRD to understand the effectiveness of the intervention in this key group. We propose 2 linked, complementary randomized trials. Trial 1, a pragmatic trial, compares usual care with a clinician-facing Jumpstart for hospitalized older adults with serious illness (n=2000). Trial 2, a comparative effectiveness trial, compares this clinician-facing Jumpstart with a bi-directional, patient-specific Jumpstart based on surveys completed by patients or family members (n=400). We hypothesize that the clinician-facing Jumpstart will improve outcomes compared to usual care, and the bi-directional, patient- specific Jumpstart will improve outcomes compared to the clinician-facing Jumpstart. We use an innovative hybrid effectiveness-implementation approach to accomplish 3 aims. Aim 1 evaluates the effectiveness of the clinician-facing Jumpstart, compared with usual care, for improving quality of care; the primary outcome is EHR documentation of a goals-of-care discussion during the hospitalization. Secondary outcomes include intensity of care at the end of life. Aim 2 evaluates the effectiveness of the bi-directional, patient-specific Jumpstart compared to the clinician-facing Jumpstart; the primary outcome is the same as Trial 1. We will examine the same secondary outcomes, but also include patient- and family-reported outcomes assessed by surveys at 1 and 3 months after randomization including occurrence and quality of goals-of-care communication in the hospital, goal-concordant care, psychological symptoms, quality of life, and palliative care needs. We will also examine costs of care after accounting for costs of the interventions. In Aim 3, we conduct a mixed-methods evaluation to explore barriers and facilitators to future implementation and dissemination. Our team has experience conducting innovative multi-center trials with patient-centered outcomes, economic analyses, and implementation science. This novel hybrid effectiveness-implementation approach addresses key knowledge gaps to improve the quality and value of care for older adults.