Improving Primary Care Clinicians' Advance Care Planning for Alzheimer's Disease and Related Dementias

高级护理计划(ACP)是在医疗团队之间进行的计划 会员和患者在严重疾病发作前，确保患者获得医疗服务 与他们的愿望和价值观相一致的关怀。阿尔茨海默病与阿尔茨海默病相关 神经退行性痴呆(AD/ADRD)是一种不治之症，进展性和终末性疾病。 对美国医疗系统、患者和家庭产生了无与伦比的影响。500多万美国人 与AD/ADRD生活在一起，AD/ADRD患者会提前数年丧失决策能力 危重和严重的疾病。临床医生必须辨别患者何时以及如何 AD/ADRD可以在AD/ADRD的所有阶段表达有效的治疗偏好。大多数患有此病的人 AD/ADRD由接受过很少教育和培训的初级保健团队成员管理 关于痴呆症的ACP技能。初级保健团队，包括医生，促进实践 提供者、护士和社会工作者处于有利地位，能够帮助AD/ADRD患者 (PLwD)及其在ACP的家人，但缺乏针对痴呆症的关键ACP技能。循证的 ACP对PLwD的干预很少见，之前没有针对AD/ADRD ACP的临床试验 初级保健。我们经验丰富的调查小组已经证明了可行性和初步 初级保健团队AD ACP干预(AD ACP工具包)的有效性。它包括一个3- 针对痴呆症的小时教育和ACP沟通技能培训课程及后续课程 非加太计划实施指南。我们将测试我们的AD ACP干预是否会启用主要 护理团队能够更有效地进行护理目标(GOC)讨论，从而提高 与控制相比举行的GOC讨论的数量。我们将交付AD ACP工具包 对10个初级保健干预诊所和10个对照诊所的日常护理使用计算机化 大型综合卫生保健系统中的病例查找算法。我们的首要目标是进行一项 关于GOC讨论和其他ACP措施的AD ACP工具包与通常关注的试验比较 800例。第二个目标是检查所有PLWD的18个月的医疗保健利用结果 干预组和对照组(N=2,660)之间有50%的5年死亡风险。我们将进行 根据关键患者和团队特征进行二次分析以检查结果。最后，我们将 通过在干预诊所(N=100)进行调查并随后进行访谈来评估实施情况 (n=60)来解释这些结果的差异。该项目针对的是美国国家研究院 老龄化的使命是改善初级保健中患有AD/ADRD的老年人的护理。这项工作将 改进初级保健团队如何将ACP方法纳入与老龄化相关的疾病 并可适用于其他门诊专科，如肿瘤科或心脏科。

Advance care planning (ACP) is the planning that takes place between healthcare team members and patients prior to the onset of serious illness to ensure a person receives medical care that aligns with their wishes and values. Alzheimer’s disease and Alzheimer’s disease related neurodegenerative dementias (AD/ADRD) are incurable, progressive and terminal diseases with unparalleled impact on the US healthcare system, patients, and families. Over 5 million Americans live with AD/ADRD, and people with AD/ADRD lose decision-making capacity years in advance of critical and serious medical illness. Clinicians must discern when and how people with AD/ADRD can express valid treatment preferences at all stages of AD/ADRD. Most people with AD/ADRD are managed by primary care team members who receive little education and training on dementia-specific ACP skills. Primary care teams, including physicians, advance practice providers, nurses and social workers, are well-positioned to empower people living with AD/ADRD (PLwD) and their families in ACP, yet lack critical dementia-specific ACP skills. Evidence-based ACP interventions for PLwD are rare, and no prior clinical trial addresses AD/ADRD ACP in primary care. Our experienced investigative team has demonstrated feasibility and preliminary efficacy of an AD ACP intervention (AD ACP Toolkit) for primary care teams. It includes both a 3- hour dementia-specific education and ACP communication skills training session and subsequent ACP implementation guidance. We will test whether our AD ACP intervention will enable primary care teams to better conduct goals of care (GOC) discussions more efficiently and thus increase the number of GOC discussions held as compared to controls. We will deliver the AD ACP Toolkit to 10 intervention primary care clinics and usual care to 10 control clinics using a computerized case-finding algorithm within a large integrated health care system. Our first aim is to conduct a trial comparing the AD ACP Toolkit to usual care on GOC discussions and other ACP measures (N=800). The second aim is to examine the 18-month healthcare utilization outcomes for all PLwD with >50% 5-year mortality risk between intervention and control (N=2,660). We will conduct secondary analyses to examine outcomes by key patient and team characteristics. Lastly, we will assess implementation via surveys in the intervention clinics (N=100) followed by interviews (N=60) to explain variations in those outcomes. This project addresses National Institute on Aging’s mission to improve care for older adults with AD/ADRD in primary care. This work will improve how to incorporate ACP approaches for aging-related conditions by primary care teams and may be adaptable to other outpatient specialties such as oncology or cardiology.