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Impact of Community Health Workers on Elderly Patients’ Advance Care Planning and Health Care Utilization

Moving the Dial

Litzelman, Debra K., MA, MD; Inui, Thomas S., ScM, MD; Griffin, Wilma J., MS; Perkins, Anthony, MS; Cottingham, Ann H., MAR, MA; Schmitt-Wendholt, Kathleen M., MPA; Ivy, Steven S., MDiv, PhD

doi: 10.1097/MLR.0000000000000675
Original Article

Background: Advance care planning (ACP) is recommended for all persons to ensure that the care they receive aligns with their values and preferences.

Objective: To evaluate an ACP intervention developed to better meet the needs and priorities of persons with chronic diseases, including mild cognitive impairment.

Research Design: A year-long, pre-post intervention using lay community health workers [care coordinator assistants (CCAs)] trained to conduct and document ACP conversations with patients during home health visits with pre-post evaluation.

Subjects: The 818 patients were 74.2 years old (mean); 78% women; 51% African American; 43% white.

Measures: Documentation of ACP conversation in electronic health record fields and health care utilization outcomes.

Results: In this target population ACP documentation rose from 3.4% (pre-CCA training) to 47.9% (post) of patients who had at least 1 discussion about ACP in the electronic health record. In the 1-year preintervention period, there were no differences in admissions, emergency department (ED) visits, and outpatient visits between patients who did and did not have ACP discussion. After adjusting for prior hospitalization and ED use histories, ACP discussions were associated with a 34% less probability of hospitalization (hazard ratios, 0.66; 95% confidence interval, 0.45–0.97), and similar effects are apparent on ED use independent of age and prior ED use effects.

Conclusions: Patients with chronic diseases including mild cognitive impairment can engage in ACP conversations with trusted home health care providers. Having ACP conversation is associated with significant reduction in seeking urgent health care and in hospitalizations.

*Regenstrief Institute Inc.

Department of Medicine, IU School of Medicine

Indiana University Health

§Department of Biostatistics, IU School of Medicine

Charles Warren Fairbanks Center for Medical Ethics, Indianapolis, IN

Supported by Grant Number 1C1CMS331000-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. This publication was also made possible by the Walther Cancer Foundation Inc., Indianapolis, IN (0122.01) and the Office of Behavioral and Social Science-National Institute of Arthritis Musculoskeletal and Skin Diseases (5R25AR060994). The research presented here was conducted by the awardee.

The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the US Department of Health and Human Services or any of its agencies.

Institutional board review (IRB) approval was obtained to conduct this study (KC IRB Protocol #: 1506203948). Consent for study enrollment was not required by the IRB because it qualified as an “exempt” study.

The authors declare no conflict of interest.

Reprints: Debra K. Litzelman MA, MD, 1101 West Tenth Street, Indianapolis, IN 46202-4800. E-mail:

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.