University of California, Los Angeles
A Pragmatic Advance Care Planning Intervention for People Living with Dementia
Health Care System Partner
University of California, Los Angeles
Dr. Walling is director of palliative care research for the Department of Medicine at the University of California, Los Angeles (UCLA), professor of medicine in the Division of General Internal Medicine and Health Services Research at UCLA, a principal investigator at the Veterans Affairs Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), a palliative care physician at the VA Greater Los Angeles Healthcare System, and assistant medical director of UCLA Health’s Advance Care Planning Program. The focus of Dr. Walling’s research has been on palliative care quality measurement and stakeholder-partnered implementation research with the goal of improving care for patients with serious illness. This award will provide the opportunity to conduct a pilot study to adapt a successful advance care planning (ACP) intervention for people living with dementia (PLWD) and establish the feasibility of a full-scale embedded pragmatic clinical trial (ePCT) evaluating the UC Health Care Planning–Dementia intervention, an electronic health record (EHR)–based intervention that also engages care partners who serve as legally authorized representatives.
RATIONALE: There is a substantial unmet need for ACP among PLWD and their care partners/legally authorized representatives (CP-LAR). The nature and trajectory of cognitive decline in dementia make early involvement of care partners and legally authorized representatives particularly important, including for PLWD who do not have access to specialized dementia care teams.
OBJECTIVE: To conduct a pilot ePCT to establish the feasibility of conducting a full-scale, clinic-level, two-arm cluster randomized ePCT that will evaluate the effectiveness of the UC Health Care Planning-Dementia intervention to improve ACP in PLWD.
SETTING: 20 UCLA primary care clinics
POPULATION: Patients seen at 20 UCLA primary care clinics with a diagnosis of dementia that are identified using a previously validated electronic health record (EHR) registry.
INTERVENTION: The UC Health Care Planning-Dementia intervention is adapted from the UC Health Care Planning Intervention which has been shown to improve rates of ACP for patients with serious illnesses other than dementia. The intervention involves the pragmatic delivery of an ACP message with PREPARE for Your Care resources through the EHR as well as the support of an ACP navigator.
FEASIBILITY ENDPOINTS AND CLINICAL OUTCOMES: Selected key feasibility endpoints include: Enrollment: Establish the feasibility of identifying 400 eligible PLWD using the EHR; Implementation: % of eligible PLWD who receive navigator triage and outreach (>75% indicates feasibility); Outcome ascertainment: % of enrolled participants for whom the clinical outcomes are ascertained from EHR data. The primary outcome for the future scale ePCT is anticipated to be formal ACP documentation (i.e. AD or POLST), with secondary outcomes including CP-LAR documentation, and goals of care communication.
IMPACT: This pilot ePCT will inform the feasibility of conducting a fully powered Stage IV ePCT evaluating the effectiveness of the UC Health Care Planning-Dementia intervention to increase ACP among PLWD and their CP-LARs in the primary care setting.