Multicenter Study

. 2017 Apr;53(4):682-692.

doi: 10.1016/j.jpainsymman.2016.11.012. Epub 2017 Jan 3.

Implementation and Impact of Patient Lay Navigator-Led Advance Care Planning Conversations

Gabrielle B Rocque¹, J Nicholas Dionne-Odom², Chao-Hui Sylvia Huang³, Soumya J Niranjan⁴, Courtney P Williams⁵, Bradford E Jackson⁶, Karina I Halilova⁴, Kelly M Kenzik⁵, Kerri S Bevis⁷, Audrey S Wallace⁸, Nedra Lisovicz⁹, Richard A Taylor², Maria Pisu⁶, Edward E Partridge⁴, Thomas W Butler¹⁰, Linda A Briggs¹¹, Elizabeth A Kvale¹²; Patient Care Connect Group

Collaborators, Affiliations

Collaborators

Patient Care Connect Group:
Lee Jackson¹³, Zoe Scott¹³, Guilherme Cantuaria¹⁴, Debbie Bickes¹⁴, Tina Berry¹⁴, George Reiss¹⁵, Hang Mai¹⁵, Ming Chang¹⁶, Louiz Gomez¹⁶, Rhonda Meeker¹⁶, James Clarkson¹⁷, Maggie Clarkson¹⁷, Steven Stokes¹⁸, Tina Newman¹⁸, Mary Sheffield¹⁹, Ellen Spremulli²⁰, Wendy Watson²⁰, Tom Payne²¹, Hanna Bright²¹, Stacey Holman²¹, Thomas Butler²², Cathy Tinnea²², Fred Schnell²³, Cyndi Pyle²³, Gabrielle B Rocque²⁴, Richard Taylor²⁴, Aras Acemgil²⁴, Xuelin Li²⁴, Kelly M Kenzik²⁴, Bradford E Jackson²⁴, Karina I Halilova²⁴, Maria Pisu²⁴, Wendy Demark-Wahnefried²⁴, Karen Meneses²⁴, Yufeng Li²⁴, Michelle Y Martin²⁴, Carol Chambless²⁴, Nedra Lisovicz²⁴, Valeria Pacheco-Rubi²⁴, Terri L Salter²⁴, Warren Smedley²⁴, Mona Fouad²⁴, Elizabeth A Kvale²⁴, Edward E Partridge²⁴

Affiliations

¹ Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA. Electronic address: grocque@uabmc.edu.
² School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA.
³ Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁴ Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁵ Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁶ Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁷ Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁸ Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁹ Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
¹⁰ University of South Alabama Mitchell Cancer Institute, Mobile, Alabama, USA.
¹¹ Gundersen Health System, La Crosse, Wisconsin, USA.
¹² Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA.
¹³ Memorial Hospital, Chattanooga, Tennesse, USA.
¹⁴ Northside Hospital Cancer Institute, Atlanta, Georgia, USA.
¹⁵ Gulf Coast Regional Medical Center, Panama City, Florida, USA.
¹⁶ Fort Walton Beach Medical Center, Fort Walton Beach, Florida, USA.
¹⁷ Singing River Health System, Pascagoula, Mississippi, USA.
¹⁸ Southeast Alabama Medical Center, Dothan, Alabama, USA.
¹⁹ Russell Medical Center, Alexander City, Alabama, USA.
²⁰ Northeast Alabama Regional Medical Center, Anniston, Alabama, USA.
²¹ Marshall Medical Center, Albertville, Alabama, USA.
²² Mitchell Cancer Institute, Mobile, Alabama, USA.
²³ Medical Center Navicent Health, Macon, Georgia, USA.
²⁴ UAB Comprehensive Cancer Center, Birmingham, Alabama, USA.

PMID: 28062341
PMCID: PMC6559345
DOI: 10.1016/j.jpainsymman.2016.11.012

Multicenter Study

Implementation and Impact of Patient Lay Navigator-Led Advance Care Planning Conversations

Gabrielle B Rocque et al. J Pain Symptom Manage. 2017 Apr.

. 2017 Apr;53(4):682-692.

doi: 10.1016/j.jpainsymman.2016.11.012. Epub 2017 Jan 3.

Authors

Collaborators

Patient Care Connect Group:
Lee Jackson¹³, Zoe Scott¹³, Guilherme Cantuaria¹⁴, Debbie Bickes¹⁴, Tina Berry¹⁴, George Reiss¹⁵, Hang Mai¹⁵, Ming Chang¹⁶, Louiz Gomez¹⁶, Rhonda Meeker¹⁶, James Clarkson¹⁷, Maggie Clarkson¹⁷, Steven Stokes¹⁸, Tina Newman¹⁸, Mary Sheffield¹⁹, Ellen Spremulli²⁰, Wendy Watson²⁰, Tom Payne²¹, Hanna Bright²¹, Stacey Holman²¹, Thomas Butler²², Cathy Tinnea²², Fred Schnell²³, Cyndi Pyle²³, Gabrielle B Rocque²⁴, Richard Taylor²⁴, Aras Acemgil²⁴, Xuelin Li²⁴, Kelly M Kenzik²⁴, Bradford E Jackson²⁴, Karina I Halilova²⁴, Maria Pisu²⁴, Wendy Demark-Wahnefried²⁴, Karen Meneses²⁴, Yufeng Li²⁴, Michelle Y Martin²⁴, Carol Chambless²⁴, Nedra Lisovicz²⁴, Valeria Pacheco-Rubi²⁴, Terri L Salter²⁴, Warren Smedley²⁴, Mona Fouad²⁴, Elizabeth A Kvale²⁴, Edward E Partridge²⁴

Affiliations

¹ Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA. Electronic address: grocque@uabmc.edu.
² School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA.
³ Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁴ Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁵ Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁶ Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁷ Division of Gynecologic Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁸ Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁹ Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
¹⁰ University of South Alabama Mitchell Cancer Institute, Mobile, Alabama, USA.
¹¹ Gundersen Health System, La Crosse, Wisconsin, USA.
¹² Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA.
¹³ Memorial Hospital, Chattanooga, Tennesse, USA.
¹⁴ Northside Hospital Cancer Institute, Atlanta, Georgia, USA.
¹⁵ Gulf Coast Regional Medical Center, Panama City, Florida, USA.
¹⁶ Fort Walton Beach Medical Center, Fort Walton Beach, Florida, USA.
¹⁷ Singing River Health System, Pascagoula, Mississippi, USA.
¹⁸ Southeast Alabama Medical Center, Dothan, Alabama, USA.
¹⁹ Russell Medical Center, Alexander City, Alabama, USA.
²⁰ Northeast Alabama Regional Medical Center, Anniston, Alabama, USA.
²¹ Marshall Medical Center, Albertville, Alabama, USA.
²² Mitchell Cancer Institute, Mobile, Alabama, USA.
²³ Medical Center Navicent Health, Macon, Georgia, USA.
²⁴ UAB Comprehensive Cancer Center, Birmingham, Alabama, USA.

PMID: 28062341
PMCID: PMC6559345
DOI: 10.1016/j.jpainsymman.2016.11.012

Abstract

Context: Advance care planning (ACP) improves alignment between patient preferences for life-sustaining treatment and care received at end of life (EOL).

Objectives: To evaluate implementation of lay navigator-led ACP.

Methods: A convergent, parallel mixed-methods design was used to evaluate implementation of navigator-led ACP across 12 cancer centers. Data collection included 1) electronic navigation records, 2) navigator surveys (n = 45), 3) claims-based patient outcomes (n = 820), and 4) semistructured navigator interviews (n = 26). Outcomes of interest included 1) the number of ACP conversations completed, 2) navigator self-efficacy, 3) patient resource utilization, hospice use, and chemotherapy at EOL, and 4) navigator-perceived barriers and facilitators to ACP.

Results: From June 1, 2014 to December 31, 2015, 50 navigators completed Respecting Choices^® First Steps ACP Facilitator training. Navigators approached 18% of patients (1319/8704); 481 completed; 472 in process; 366 declined. Navigators were more likely to approach African American patients than Caucasian patients (20% vs. 14%, P < 0.001). Significant increases in ACP self-efficacy were observed after training. The mean score for feeling prepared to conduct ACP conversations increased from 5.6/10 to 7.5/10 (P < 0.001). In comparison with patients declining ACP participation (n = 171), decedents in their final 30 days of life who engaged in ACP (n = 437) had fewer hospitalizations (46% vs. 56%, P = 0.02). Key facilitators of successful implementation included physician buy-in, patient readiness, and prior ACP experience; barriers included space limitations, identifying the "right" time to start conversations, and personal discomfort discussing EOL.

Conclusion: A navigator-led ACP program was feasible and may be associated with lower rates of resource utilization near EOL.

Keywords: Advance care planning; end of life; lay navigation; lay navigator.

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Figures

**Fig. 1.**
Mixed-method study schema. PCCP = Patient Care Connect Program; ACP = advance care planning.

**Fig. 2.**
Self-efficacy results. ACP = advance care planning.

See this image and copyright information in PMC

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Implementation and Impact of Patient Lay Navigator-Led Advance Care Planning Conversations

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Implementation and Impact of Patient Lay Navigator-Led Advance Care Planning Conversations

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