改善 ADRD 患者的 PCP 预先护理计划 (AD-ACP)

1. Dementia-specific education: Stage-specific findings and challenges, including AD/ADRD staging, capacity assessment, symptom burden, hospice guidelines, etc - 10-minute didactics, delivered via video conferencing and via the website
2. ACP communication skills: Context-specific skills and tips on how to slow down, set the communication stage, active listening, respect for personhood and cultural norms, and common, useful language to prepare patients and families- 10-minute didactics, delivered via video conferencing and via the website
3. Clinical implementation support: Coding and billing information for ACP and ACP templates, an action plan for each team member participant, monthly ACP audit-and-feedback to participants, monthly coaching sessions, site champion, refresher sessions, and educational in-services as needed - Resources at the end of the training session, available on the website, monthly feedback reports on ACP practices, periodic coaching

Included in arm/group descriptions

• AD-ACP

These primary care teams will not receive the Advance Care Planning training. Clinics randomized to the control arm will have access to voluntary, routine ACP training sessions provided by UNC HEALTH. We will provide the control clinics summary reports of their ACP practice outcomes at the end of the 18-month follow-up period, which can be used in future practice improvement efforts.

Included in arm/group descriptions

Presence of a documented Goals of Care (GOC) discussion between the primary care team member and the Person Living with Dementia (PLwD) or their surrogate decision-maker. Medical record documentation of discussion must include a) communication about dementia stage or prognosis AND b) decision-making for at least one major treatment: CPR/mechanical ventilation, hospitalization, treatments for infections, artificial/feeding/hydration, OR hospice.

Choice of a surrogate decision-maker for the PLwD documented in the medical record.

Assessment and report of decision-making capacity for the PLwD documented in the medical record.

Completion of portable ACP orders using a state-approved DNR or POLST form documented in the medical record.

Discussion of prognosis or future medical complications of Alzheimer's Disease/Alzheimer's Disease and Related Dementias (AD/ADRD) between the primary care team member and the PLwD or their surrogate decision-maker documented in the medical record.

Number of emergency room visits and hospital admissions.

The percentage of active users at each clinic who have completed at least one training of either type

Duration of hospitalizations from day of admission to day of discharge.

Percent of PLwD with a referral order to Palliative Care in the medical record.

Percent of PLwD with a referral order to Hospice in the medical record.

Number of documented code status and health care proxy in the medical records

Scores of Organizational Readiness to Implementing Change (ORIC) - range 12-60 with higher scores indicating greater organizational readiness

Scores of Intervention Appropriateness Measure (IAM) - range 4-20 with higher scores indicating greater appropriateness

Scores of Feasibility of Intervention Measure (FIM) - range 4-20 with higher scores indicating greater feasibility

Scores of primary care team members on post-intervention quizzes, participation in clinic-level and primary care team member-level ACP audit-and-feedback, refresher sessions and in-services, periodic coaching from the research team.