AHRQ Innovations Exchange | Counseling and Care Coordination for Patients With Advanced Illness Lead to More Patients Completing Advance Directives and Less Use of Inpatient Care

Counseling and Care Coordination for Patients With Advanced Illness Lead to More Patients Completing Advance Directives and Less Use of Inpatient Care


Snapshot
Summary
Working in three Kaiser Permanente clinics in the western U.S., Care Support of America, University at Albany and Kaiser Permanente clinical leaders collaborated to evaluate the Advanced Illness Coordinated Care Program to help patients with advanced illnesses who do not yet qualify for hospice care better understand their illnesses, communicate with providers, and obtain any palliative care and support they may need. Social workers met with patients and caregivers over a 6- to 12-week period to help them access medical care resources and pain relief, cope with the loss of functional capabilities, obtain spiritual and emotional support, and prepare for end-of-life care. The program improved patient-provider communication, the quality of care related to physical and emotional discomfort, decisionmaking support, and spiritual/emotional support; increased the percentage of patients completing advance directives; and reduced hospitalizations and produced a nonsignificant trend for fewer emergency department visits. The program is currently expanding to other Kaiser Permanente clinics.

Evidence Rating
Strong: The evidence consists of a randomized controlled trial that compared key metrics for 198 program participants to the same metrics for 205 similar patients receiving usual care; metrics included patient ratings of the quality of patient-provider communication, care for physical and emotional discomfort, decisionmaking and spiritual/emotional support; the likelihood of completing an advance directive; and utilization of various health care services.



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AHRQ Innovations Exchange | Counseling and Care Coordination for Patients With Advanced Illness Lead to More Patients Completing Advance Directives and Less Use of Inpatient Care