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Integration of an Advance Care Planning Model in Home Health

Favorable Outcomes in End-of-Life Discussions, POLST Rates, and 60-day Hospital Readmissions

Mauleon, Jessica DNP, AGPCNP-C; Staffileno, Beth A. PhD, RN, FAHA

doi: 10.1097/NHH.0000000000000797

Only 2.3% of patients at a Midwest home healthcare (HH) agency had documented advance directives (ADs), compared with 28% nationally. Of concern, this HH agency lacked standardized procedures for advance care planning (ACP) leading to inadequate staff knowledge regarding end-of-life, avoidable hospital readmissions, and delayed transitions into hospice care. Lack of ADs is directly correlated to higher hospital readmission rates and lower hospice length of stay. The purpose of this initiative was to develop evidence-based procedures using the Respecting Choices® ACP model to: 1) educate staff, 2) increase ACP conversations offered and completed among high-risk patients, 3) increase Practitioner Orders for Life-Sustaining Treatment (POLST) rates, 4) reduce 60-day hospital readmissions, and 5) support hospice care admissions. Staff received discipline-specific education on ACP/ADs. The Knowledge-Attitudinal-Experiential Survey on Advance Directives (KAESAD), assessed staff ACP/AD knowledge, confidence, and experiences. Standardized electronic medical record tools were created to track ACP conversations, POLST rates, 60-day hospital readmissions, and hospice admissions. Paired t-test and chi-square analyses compared changes pre- and post implementation. The KAESAD survey was analyzed for 75 staff (100%) and demonstrates improvement in knowledge, confidence, and experiences. Data also demonstrate increases in: ACP offered 6% to 80% (p < .001); ACP conversations completed 4% to 31% (p < .001); POLST rates 26% to 43.6% (p = .059); decreased 60-day hospital readmissions 40% to 20% (p = .025); whereas hospice care admissions was not impacted ranging from 10% to 5.5% (p = .381). Respecting Choices® serves as an effective ACP framework to improve ACP conversations, POLST rates, and hospital readmissions.

Jessica Mauleon, DNP, AGPCNP-C, is a Nurse Practitioner at an Internal Medicine practice in Lincolnshire, Illinois.

Beth A. Staffileno, PhD, RN, FAHA, is an Associate Professor, Co-Director Center for Clinical Research and Scholarship, College of Nursing, Rush University, Chicago, Illinois.

The authors declare no conflicts of interest.

Address for correspondence: Jessica Mauleon, DNP, AGPCNP-C (

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