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

预先护理计划（ACP）是在医疗团队之间进行的计划 在严重疾病发作之前，确保成员和患者接受医疗 照顾符合他们的愿望和价值观。阿尔茨海默病和阿尔茨海默病相关 神经退行性痴呆（AD/ADRD）是不可治愈的、进行性的和晚期的疾病， 对美国医疗系统、患者和家庭产生了无与伦比的影响。超过500万美国人 患有AD/ADRD的人，AD/ADRD患者提前数年丧失决策能力 严重和严重的医疗疾病。临床医生必须辨别何时以及如何与人 AD/ADRD可以在AD/ADRD的各个阶段表达有效的治疗偏好。大多数人 AD/ADRD由接受很少教育和培训的初级保健团队成员管理 专门针对痴呆症的ACP技能初级保健团队，包括医生，先进的做法 提供者，护士和社会工作者，有能力赋予AD/ADRD患者权力 （PLwD）及其家人在ACP，但缺乏关键的痴呆症特异性ACP技能。循证 针对PLwD的ACP干预很少见，并且既往没有临床试验针对AD/ADRD ACP， 初级保健.我们经验丰富的调查团队已经证明了可行性和初步 AD ACP干预（AD ACP工具包）对初级保健团队的有效性。它包括一个3- 小时专门针对痴呆症的教育和ACP沟通技能培训课程， 非加太执行指南。我们将测试我们的AD ACP干预是否将启用主要 护理团队更有效地进行护理目标（GOC）讨论，从而提高 与对照组相比，GOC讨论的次数。我们将提供AD ACP工具包 向10个干预初级保健诊所和10个控制诊所提供常规护理， 在一个大型综合医疗保健系统中的病例发现算法。我们的第一个目标是进行一次 将AD ACP工具包与GOC讨论和其他ACP措施的常规护理进行比较的试验 （N=800）。第二个目的是检查所有PLwD的18个月医疗保健利用结果 干预组和对照组之间的5年死亡率风险>50%（N= 2，660）。我们会进行 二次分析，以检查关键患者和团队特征的结局。最后，我们将 通过在干预诊所（N=100）进行调查，然后进行访谈，评估实施情况 （N=60），以解释这些结果的变化。该项目涉及国家研究所， 老龄化的使命是改善初级保健中AD/ADRD老年人的护理。这项工作将 改善初级保健团队如何将ACP方法用于与衰老相关的疾病 并且可以适用于其它门诊专科，例如肿瘤科或心脏科。

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.