Increasing Advance Care Planning and Advance Directive Discussion in Primary Care Settings

Advance care planning (ACP) and advance directives (ADs) involve an active medical decision making process regarding one's end-of-life care in the event that a patient becomes incapacitated. The process includes patients and family members as well as well-trained, motivated, knowledgeable health care providers who are willing to initiate such discussions and provide the necessary information to make informed decisions. The goal of this project is to increase advance directive discussions in primary care settings by increasing the knowledge and comfort level of primary care providers (PCPs). Currently, there is a lack of ACP and AD discussions in primary care settings although the need to initiate ACP and AD discussions is rising. An increasing number of people are suffering from chronic illnesses and this raises their risks of receiving invasive life-prolonging measures, even if it is against their wishes. PCPs are in a key position to initiate the discussion while patients are still physically and mentally well. ACP and ADs coincide with basic medical ethics including autonomy, beneficence, and non-maleficence. The biggest advantage of having an ACP and AD in place is so care-givers can respect a patient's autonomy by following advance directives. This may also decrease the unnecessary burden on family members and healthcare providers to make health care decisions for their loved ones and patients. There are many obstacles for PCPs to initiate such discussions. This includes time limitations, the sensitivity of the topic, difficulty identifying the right moment to initiate such discussions and a lack of awareness of ACP and ADs. However, there are also facilitators for PCPs to initiate the discussion. These include a PCP's perceived usefulness of ACP and ADs and reimbursement for time spent on ACP and AD discussion by the center of Medicaid and Medicare The goal of this project was to increase the number of PCPs that initiate this discussion with their patients in the primary care setting and to increase the knowledge and comfort levels of PCPs with the discussion. To achieve this goal, an educational presentation and algorithm were developed and these materials were presented in a primary care setting. To evaluate the effectiveness of the presentation, pre- and post-educational surveys were conducted. In addition, data for the use of the CPT codes for ACP discussions was collected and analyzed for outcome measurements one month before the presentation and one month after. The pre and post-educational surveys showed an increase in knowledge about ACP and ADs knowledge (3.00 ±1.27 pre-education, and 4.33 ± 1.03 post-education, Wilcoxon p value =0.046) and there is a trend toward a significant difference in PCP's wiliness to use CPT codes after the presentation (1.00 ± 0.00 prior and 2.67 ± 1.51 after the presentation, Wilcoxon p= 0.059). However, one month after the presentation, there was no difference in actual CPT code usage by providers. These results may suggest that PCPs perceived obstacles bigger than expected or one-month is too short to follow-up and measure meaningful changes in practice. Furthermore, except financial compensation, PCPs may require an extra layer of support and training to facilitate ACP/AD discussions.

Running head: ADVANCE CARE PLANNING Increasing Advance Care Planning and Advance Directive Discussion in Primary Care Settings Yeo Young Yoon, BSN, RN, DNP Student University of Utah College of Nursing In partial fulfillment for the requirements of the Doctor Nursing Practice 1 ADVANCE CARE PLANNING 2 Executive Summary Advance care planning (ACP) and advance directives (ADs) involve an active medical decision making process regarding one's end-of-life care in the event that a patient becomes incapacitated. The process includes patients and family members as well as well-trained, motivated, knowledgeable health care providers who are willing to initiate such discussions and provide the necessary information to make informed decisions. The goal of this project is to increase advance directive discussions in primary care settings by increasing the knowledge and comfort level of primary care providers (PCPs). Currently, there is a lack of ACP and AD discussions in primary care settings although the need to initiate ACP and AD discussions is rising. An increasing number of people are suffering from chronic illnesses and this raises their risks of receiving invasive life-prolonging measures, even if it is against their wishes. PCPs are in a key position to initiate the discussion while patients are still physically and mentally well. ACP and ADs coincide with basic medical ethics including autonomy, beneficence, and non-maleficence. The biggest advantage of having an ACP and AD in place is so care-givers can respect a patient's autonomy by following advance directives. This may also decrease the unnecessary burden on family members and healthcare providers to make health care decisions for their loved ones and patients. There are many obstacles for PCPs to initiate such discussions. This includes time limitations, the sensitivity of the topic, difficulty identifying the right moment to initiate such discussions and a lack of awareness of ACP and ADs. However, there are also facilitators for PCPs to initiate the discussion. These include a PCP's perceived usefulness of ACP and ADs and reimbursement for time spent on ACP and AD discussion by the center of Medicaid and Medicare The goal of this project was to increase the number of PCPs that initiate this discussion with their patients in the primary care setting and to increase the knowledge and comfort levels of PCPs with the discussion. To achieve this goal, an educational presentation and algorithm were developed and these materials were presented in a primary care setting. To evaluate the effectiveness of the presentation, pre- and post-educational surveys were conducted. In addition, data for the use of the CPT codes for ACP discussions was collected and analyzed for outcome measurements one month before the presentation and one month after. The pre and post-educational surveys showed an increase in knowledge about ACP and ADs knowledge (3.00 ±1.27 pre-education, and 4.33 ± 1.03 post-education, Wilcoxon p value =0.046) and there is a trend toward a significant difference in PCP's wiliness to use CPT codes after the presentation (1.00 ± 0.00 prior and 2.67 ± 1.51 after the presentation, Wilcoxon p= 0.059). However, one month after the presentation, there was no difference in actual CPT code usage by providers. These results may suggest that PCPs perceived obstacles bigger than expected or one-month is too short to follow-up and measure meaningful changes in practice. Furthermore, except financial compensation, PCPs may require an extra layer of support and training to facilitate ACP/AD discussions. Expertise and support for this project are being endowed by the project committee, which is comprised of project chair, Nancy Allen, PhD, ANP-BC; family nurse practitioner specialty track director, Julie Balk, DNP, APRN, FNP-BC, CNE; the assistant dean of MS and DNP programs, Pamela Hardin, PhD, RN, CNE; and content experts, Holli Martinez, FNP-BC, ACHPN. ADVANCE CARE PLANNING 3 Table of Contents Executive Summary……………………………………………………………………………...2 Acknowledgements………………………………………………………………………………5 Introduction………………………………………………………………………………………6 Problem Statement………………………………………………………………………...6 Clinical Significance………………………………………………………………………7 Purpose and Objectives……………………………………………………………………8 Literature Review………………………………………………………………………………..9 Search Strategy……………………………………………………………………………9 Introduction………………………………………………………………………………..9 Current Use of ACP and ADs……………………………………………………………..9 Significance of ACP and ADs……………………………………………………………10 Barriers of ACP and ADs………………………………………………………………...11 Facilitators of ACP and ADs……………………………………………………………..13 Conceptual Framework………………………………………………………………………...14 Implementation and Evaluation Plan…………………………………………………………14 Implementation and Evaluation……………………………………………………………….17 Objective 1……………………………………………………………………………….17 Objective 2……………………………………………………………………………….17 Objective 3……………………………………………………………………………….18 Objective 4……………………………………………………………………………….19 Results…………………………………………………………………………………………...20 Positive Unintended Consequences……………………………………………………………23 Future Recommendations……………………………………………………………………..24 ADVANCE CARE PLANNING 4 Doctor of Nursing Practice Essentials…………………………………………………………25 Conclusion………………………………………………………………………………………27 References……………………………………………………………………………………….29 Appendices………………………………………………………………………………………29 Appendix A. DNP Project Proposal PowerPoint………………………………………...31 Appendix B. Institutional Review Board Exemption……………………………………39 Appendix C. ACP Educational PowerPoint Presentation………………………………..41 Appendix D. Pre-education Survey……………………………………………………...55 Appendix E. Post-education Survey……………………………………………………..58 Appendix F. Pre and Post-test Survey Results…………………………………………..61 Appendix G. Final DNP Project Poster………………………………………………….65 Appendix H. Rocky Mountain Geriatric Conference Abstract…………………………..67 ADVANCE CARE PLANNING 5 Acknowledgements Thank you, Dr. Nancy Allen, for your unceasing support, feedback and guidance Thank you to my family, especially my husband, Troy Sienko, for constant encouragement and loving support ADVANCE CARE PLANNING 6 Increasing Advance Care Planning and Advance Directive Discussion in Primary Care Settings Problem Statement Advance care planning (ACP) describes an active medical decision making process across the entire lifespan in preparation for future healthcare management. ACP involves not only patients and family members but also requires well-trained, motivated and supportive medical and healthcare providers who are ready and willing to initiate discussions and provide the necessary information for decision makers so they can make informed decisions. The need to discuss and facilitate ACP is increasing for the aging baby boomer generation. It is estimated that the number of older adults in the U.S. will increase to fifty million by the year 2020, but currently less than 30% of the population has an advance directive in place (Hinders, 2012). ACP discussions often occur when patients receive a new diagnosis of a chronic or terminal disease, experience exacerbation of these conditions or when there is a transition of care, such as discharge from a hospital or placement in a nursing home (Ahia & Blais, 2014). These are all common situations that a primary care provider faces daily. However, many primary care providers do not feel comfortable talking about ACP with their patients unless there is an imminent need (Jolien, Moll van Charante, & Willems, 2015). In addition, dealing with the daily, busy, clinical work, ACP discussions may not be addressed at primary care provider (PCP) visits. Primary care providers are in a key position to initiate advance directives when patients are still well physically and/or mentally. Recently, ACP has received increased attention from a public health perspective since it has the possibility to prevent unnecessary suffering and to advocate a person's decisions, values, and preferences regarding end-of-life care (Center for Disease and Prevention [CDC], 2011). The goal of this DNP project is to increase the knowledge ADVANCE CARE PLANNING 7 and comfort of PCPs in initiating ACP discussions and enhance people's awareness regarding ACP and advance directives (ADs). The target population is baby boomers and older, especially ones with chronic progressive illnesses or terminal conditions. Clinical Significance Pealrman (2013) stated that the goals of ACP and AD coincide with the basic principles of medical ethics including autonomy, beneficence and non-maleficence. ACP and ADs promote a patient's autonomy by respecting self-determination regarding the care decisions based on his or her values, preferences, and personal goals (Pealrman, 2013). They also endorse beneficence and non-maleficence by reducing the chance of over or under treatments against a patient's wishes, decreasing the likelihood of conflicts and the burden of decision making among family members (Pealrman, 2013). It seems obvious how these ethics may benefit individual patients and family members if ADs are in place. With the current, ever-advancing medical technology, it is hard to gauge how much aggressive treatments a patient wants without a clearly written AD (CDC, 2011). This would increase ethical dilemmas for medical providers. Moreover, utilizing high tech medical care which may not necessarily improve quality of life (CDC, 2011) and may increases the individuals and societies financial burden. Currently less than 30% of the population (Hinders, 2012) and fewer than 50% of terminally ill patients have an AD in place (CDC, 2011). With this in mind, there is great potential that the number of patients who do not have an AD will increase in the near future with the aging baby boomer generation. The CDC brief (2011) pointed out that it is very likely that an older adult will suffer from multiple chronic illnesses and experience extensive disability prior to death. Without an ACP and an AD in place, many patients will suffer from unwanted medical treatments, increase the burden of decision-making for family members and caregivers, add ADVANCE CARE PLANNING 8 financial problems to the individual's family and society, and more importantly, a patient's quality of life will suffer. The biggest advantage of having an ACP and AD in place is to respect a patient's autonomy. Even when a patient is not capable of making their own medical decisions, ideally his or her wishes will be respected based on the AD. Beneficence and non-maleficence would follow by following an individual patient's wishes and values. This may decrease unnecessary suffering, improve quality of care and decrease conflicts among family members. So far, there is a lack of communication regarding ACP and AD, especially in the primary care setting. With the aging baby boomer generation in mind, the author wants to highlight the important role that a primary care provider can play in increasing the number of patients who have an ACP and AD in place and the impact this increase will have on society and public health standards in general. Purpose and Objectives The primary goal of the scholarly project is to increase knowledge and comfort of PCPs in initiating ACP discussions or to facilitate PCPs discussions of ACP by establishing a guideline and/or algorithm to facilitate an advance directive discussion and advance care planning between primary care providers and patients in the primary care setting. The objectives of this project include: 1. Improve PCP's awareness and comfort levels regarding ACP and ADs. 2. Develop an educational module supported by the most current and evidence-based recommendations. 3. Implement an educational presentation in a primary care setting and evaluate the project effectiveness with pre- and post-educational presentation surveys. ADVANCE CARE PLANNING 9 4. Disseminate the outcome of the project to local health care departments and in a poster presentation. Literature Review Search Strategy For literature review, the author used the search terms "advance care planning," "advance directives," AND "primary care providers," "statistics," "benefits," "obstacles," "facilitators," "public health," "clinical guidelines," "algorithm," using the databases such as PubMed, CINAHL, and Google Scholar. Introduction Advance Care Planning (ACP) addresses an individuals' preference, values and wishes for their medical care in the future in the case that he or she cannot make their own medical decisions if incapacitated. It is a process of decision making between medical providers, patients and family members regarding end-of-life care (Jolien et al., 2015). It includes informing patients regarding their disease progress, prognoses, and care options as well as informing health care providers and family members about the patients' preferences, values, beliefs, and treatment choices for potential future medical situations (Jolien et al., 2015). Although a discussion of ACP often occurs with older adults, it is for all adults who want to prepare for "what-if" situations across their entire lifespan, either sick or well (CDC, 2011). Advance directives (ADs) are written and official documents that allow competent patients to express their future health care preferences and choices in case they are incapacitated (Wheatley & Huntington, 2012). Current Use of ACP and ADs It is estimated that the number of older adults in the U.S. will increase to fifty million by the year 2020 but currently less than 30% of the population has an advance directive in place ADVANCE CARE PLANNING 10 (Hinders, 2012). Approximately 28% of community dwelling older adults, 65% of nursing home residents and 88% of hospice care patients have ADs in place (CDC, 2011). Even among terminally ill patients, those who have ADs in place is fewer than 50% (CDC, 2011). Overall, only 18% to 36% of Americans completed ADs and approximately two thirds of medical providers are not aware if ADs are present (U.S. Department of Health & Human Services, 2008). Currently, ACP and ADs discussions mostly occur with patients with terminal illnesses, such as cancer patients, and in institutional settings, such as a nursing home or hospice, since some of these institutions require mandatory ACP and AD discussions. This suggests that there is a relative lack of discussions about ACP and ADs in primary care settings compared to others. However, in their study, Allen et al. (2015) stated that 74% of patients who had no AD in place wanted to talk to their providers about the topic in an ambulatory care setting. This reflects that there is a growing need to discuss ACP and ADs in primary care settings that PCPs should address. The significance of ACP and ADs. Advance care planning (ACP) describes an active medical decision making process across the entire lifespan in preparation for the worst. Pealrman (2013) stated that the goals of ACP and AD coincide with the basic principles of medical ethics including autonomy, beneficence and non-maleficence. ACP and ADs promote a patient's autonomy by respecting self-determination regarding the care decisions based on his or her values, preferences, and personal goals (Pealrman, 2013). They also endorse beneficence and non-maleficence by reducing the chance of over or under treatments against a patient's wishes as well as decreasing the likelihood of conflicts and the burden of decision making among family members (Pealrman, ADVANCE CARE PLANNING 11 2013). It seems obvious how these ethics may benefit individual patients and family members if ADs are in place. Without ADs in place, there is an increased potential that a medical provider would face a situation where they would have to treat a patient with aggressive medical regimens for a prolonged period of time without improving their quality of life, which does not coincide with respecting a patient's autonomy, beneficence, or non-maleficence. Additionally, ACP has received increased attention from a public health perspective since ADs have the possibility to prevent unnecessary suffering and to advocate a person's decisions, values, and preferences regarding end-of-life care (CDC, 2011). By respecting a patient's known wishes, it may decrease the cost of end-of-life care by reducing unwanted invasive treatments and intensive care unit (ICU) or hospital stays. This could be a secondary benefit of having ACP and ADs in place and might naturally reduce overall medical costs and financial burdens for society. Barriers of ACP and ADs. Although primary care providers are in the best position to initiate ACP and ADs discussion because of their long-standing, trusted relationships with patients, many providers are hesitant to start the conversation due to the sensitive and time-consuming nature of these topics (Allen et al., 2015). Most PCPs work in an environment where they have to deal with high acuity patients in short appointment times and need to yield high productivity. When discussing ACP, PCPs face explaining the complexity of illnesses to patients and family members as well as dealing with emotional distress. For this reason, when it occurs, these discussions mostly take place when patients develop progressive serious illnesses or terminal diseases (Allen et al., 2015). Additionally, many medical providers have difficulty identifying when and how to initiate such conversations hence have challenges in practicing ACP in a systemic way (Jolien et al., 2015). ADVANCE CARE PLANNING 12 PCPs have stated that some of the perceived barriers for initiating the discussions are dealing with the uncertainty of prognosis, ambiguous requests from patients, challenges managing patient's changing preferences, consider curing disease as their job, thinking other professionals may be better equipped to have ACP discussions, believe patients should initiate the discussion, fear of upsetting patients and family and anticipating adverse effects of the discussion such as fear of taking away hope or damaging the patient-provider relationship (De Vleminck et al., 2013). Other barriers to ACP and ADs for patients include lack of awareness, denial, confusion, and cultural differences (CDC, 2011). Patients and family members may not know about ACP and ADs and if their providers do not engage in such discussions, they might not even have a chance to talk about them and let their wishes be known. In such cases, medical providers are not aware of their patients' wishes and preferences about end-of-life care and miss the opportunity to incorporate them into ADs. According to the SUPPORT study sponsored by the Robert Wood Johnson Foundation, approximately one third of terminally ill patients did not want cardiopulmonary resuscitation but less than half of their physicians were aware of their wishes (CDC, 2011). Denial of death and dying is a part of our culture and makes it challenging for some patients to express their wishes and preferences about end-of-life care (CDC, 2011). People influenced by this culture avoid talking about death and dying as a natural part of life events and lose a chance to make their own decisions and speak for themselves (CDC, 2011). There are some people that believe that having ACP and ADs in place may interfere with their future medical care that may help them extend their lives as long as possible (CDC, 2011). This confusion is one of the barriers to having ACP and ADs in place. ADVANCE CARE PLANNING 13 The final barrier to consider is cultural differences. A CDC brief (2011) stated that although the majority of minority patients wish to die at home and do not want to receive lifesustaining treatments with painful side effects to extend their life for one week to one month, minority patients are more likely to die at a hospital and receive life-sustaining treatments in intensive care units compared to whites. This is partially due to a low usage of hospice services and ADs among minority patients (CDC, 2011). Facilitators of ACP and ADs PCPs recognize the amount of their experience and having a living will themselves as a facilitator for ACP discussions (De Vleminck et al., 2013). In addition, acknowledging ACP discussions as their part of job and having an attitude to initiate ACP discussion instead of waiting for patients to initiate it are also shown to be facilitators (De Vleminck et al., 2013). Having a positive experience with ACP discussions formerly and perceiving the usefulness of ACP and AD discussions are also facilitators to this discussion by PCPs (De Vleminck et al., 2013). One of the biggest barriers for a PCP to initiate ACP and AD discussion is short appointment times and the accompanying time constraints. The Center of Medicare and Medicaid (2016) started reimbursing the time spent on the discussion of ACP and ADs to healthcare providers. Since January 2016, Medicare reimburses ACP as a separate service provided by medical providers and this includes office visits and institutional settings, including hospitals (Kaiser Family Foundation.org, 2015). A qualified healthcare provider who provides information and counseling about ACP and ADs to beneficiaries, family members, and proxy can use CPT code 99497 for the first thirty minutes of an appointment. Moreover, every additional thirty minutes spent can be billed by CPT code 99498 (Center for Medicare and Medicaid ADVANCE CARE PLANNING 14 Services [CMMS], 2016). The CMMS (2016) has not put a limitation on the number of times that a beneficiary can be counseled by a provider and there is no location limitation, which means that a beneficiary can receive this service wherever they deem to be appropriate such as primary care settings, acute care hospitals, or senior residential facilities. The completion of an AD is not a requirement to bill these codes as long as counsel is being provided (CMMS, 2016). A healthcare provider can conduct this counseling on the same day of scheduled office visits when managing other chronic conditions, handling transitional care occurrence or, during a separate office visit (CMMS, 2016). Conceptual Framework The theory chosen for the doctor of nursing practice (DNP) project is informationprocessing theory. This theory analyzed how human beings process information, encode it and store it as short and long-term memory and retrieve it when it is necessary (Lutz & Huitt, 2003). Huitt (2000) stated that most information processing theories agree that there is a limitation on how much and what percentage of information could be processed, encoded and stored at one time (Lutz & Huitt, 2003). Based on this information, the educational materials were presented in a concise and precise format yet delivered the key points of the project. Additionally, the authors stated that, for most people, the maximum number of stimuli that can be processed at one time is 5± 2. Based on this information, the presentation of information was presented with a maximum of five bullet points under one topic. The authors also stated that one of the keys to learning new information is integrating new information with stored information. The strategy in developing a clinical guideline is to remind primary care providers (PCPs) of existing knowledge and the need of having discussions about advance care planning (ACP) and advance directives (ADs) and add new information, such as appropriate approach and communication skills, to ADVANCE CARE PLANNING 15 maximize learning. Short phrases were provided to remind PCPs of the importance and necessity of discussing ACP and ADs and incorporate a therapeutic approach for PCPs to utilize when they discuss ACP and ADs with their patients. When developing the implementation of the guidelines, the Sternberg's (1998) model is very helpful (Lutz & Huitt, 2003). Sternberg's theory is one of various informational theories that Lutz and Huitt (2003) introduced in their article. Sternberg's information processing model proposed three stages of learning: metacomponents, performance components, and knowledgeacquisition. Learners identify problems which connect to their past in the metacomponent stage, take actions and weigh the pros and cons related to their actions, and finally, in the knowledgeacquisition stage, learners acquire new knowledge and can use it to solve potential problems. During the development of the educational module, the problems related to low completion of ADs was presented with examples that PCPs could encounter easily in their daily practice settings. The next step would be to present intelligent scenarios associated with their actions or non-action around ACP and ADs and encourage them to learn or adopt this new recommendation to produce better outcomes for patients and their families. This theory supports the potential design of the DNP project and helps to facilitate learning and retention of what people have learned and reinforces the decision making process to act on what they have learned. Implementation and Evaluation Plan Table 1 Project Objectives and Related Implementation and Evaluation Plan Objectives 1. Improve PCP's awareness and comfort levels Implementation • Submitted an application for the Evaluation • IRB approval was obtained ADVANCE CARE PLANNING regarding advance care planning (ACP) and advance directives (ADs) 2. Develop a clinical guideline supported by the most current and evidence-based recommendations 16 • • • 3. Implement an educational presentation in a primary care setting • • • 4. Disseminate the outcome of the project to a larger audience • • project to Institutional Review Board (IRB) Identified facilitators and barriers of AP and AD discussions and developed a strategy to overcome barriers Developed educational power point materials based on the literature review and consulted with the content expert Created an algorithm for medical assistants and PCPs to screen patients who may require ACP and ADs Educational presentation was provided during staff meeting at Stansbury University of Utah clinic to PCPs and MAs Evaluated the project effectiveness with the pre and post-surveys after an educational presentation Evaluated the CPT code 99487, 99488 use in one month before and after presentation Presented the project outcome to the clinical site and local aging services Submitted an abstract to Rocky Mountain Geriatric Conference • • • • • • Obtained approval for Power point presentation from project chair Obtained approval for developed algorithms Conducted a pre- and post-test survey Conducted analysis of the CPT code use through coders Submitted the result of statistical analysis to the project chair for review and approval Presented a copy of abstract and a proof of submission to the conference to the project chair ADVANCE CARE PLANNING 17 Implementation and Evaluation Objective 1. Improve PCP's awareness and comfort levels regarding advance care planning (ACP) and advance directives (ADs) First, the author submitted an application to the Institutional Review Board (IRB) at the University of Utah to obtain approval for the study. This process started in early December 2016 so as not to hamper the submittal of the application on time. Before submitting the application to the IRB, the chair reviewed the application and approved it. The exemption from the IRB was obtained and the proof of exemption was provided to the project chair (see appendix B). To improve primary care provider's knowledge, awareness, and comfort levels discussing ACP and ADs, it was critical to identify what the obstacles and facilitators for such discussions are. For that reason, review of literature helped identify the major factors that may hinder or facilitate ACP and ADs discussions between PCPs and patients. Additionally, an exploration of data proved to be useful. Reviewing current statistics involving ACP and AD discussions showed the implication on the low rate of AD completion by the aging baby boomer generation. The content expert and the project chair provided support and guidance while the author was performing this project and constructing strategies to overcome obstacles and enhance facilitation. The author also shadowed social workers and case managers to experience how they interact and teach patients and family members regarding ACP discussions and AD completion. Through literature review, consultations with a content expert and project chair, and first-hand experience with social workers, the author developed strategies to overcome the obstacles and enhance facilitation. The chair had a chance to review the strategies for approval. Objective 2. Develop a clinical guideline supported by the most current and evidence-based recommendations ADVANCE CARE PLANNING 18 Over three semesters, the author conducted literature review to find the most current and evidence-based recommendations about ACP and AD practices among PCPs. Currently, most literature on the ACP and AD discussions is limited to older adults with progressive chronic or terminal conditions. For example, even among terminally ill patients, the Center for Disease Control reports an AD completion rate of less than 50% and less than 30% of older adults has completed ADs (CDC, 2011). Therefore, there was a need to develop the educational materials to facilitate AD discussion among PCPs. After having completed a comprehensive review of the research done in the field, the author realized that there are many obstacles preventing PCPs from having such discussions. To overcome these obstacles, findings from the literature review, the content expert's knowledge and experiences and feedback from the project chair were incorporated in developing the educational materials that would be applicable for use in primary care settings. The developed content was translated into a PowerPoint presentation and the educational material was presented in a primary care setting. An algorithm to help Medical Assistants screen patients who have or have not completed an advance directive and whether or not they are aware of an AD was developed. In addition, a separate algorithm to assist PCPs navigate through ACP and AD discussions was also created. During this process, the author contacted the project chair and content expert multiple times to seek guidance and professional knowledge and revised the materials as advised. The project chair reviewed the final PowerPoint educational materials prior to the presentation in a primary care setting. Objective 3. Implement an educational presentation in a primary care setting The author contacted a primary care clinic that mainly sees adult and older adults patients to seek an approval to present the educational presentation to the staff. The targeted clinic had six ADVANCE CARE PLANNING 19 PCPs practicing at the time of the presentation. After selecting an appropriate site for the project and developing the educational materials (see appendix C), the author conducted an educational presentation at the clinic during their staff meeting. Before the educational presentation, the author handed out the pre- and post-presentation questionnaires (see appendix D and E) to assess the PCP's knowledge, awareness, current practice and comfort levels regarding ACP and AD discussions. The project chair reviewed and approved these questionnaires prior to the presentation. PCPs were asked to fill out these questionnaires before and after the presentation, respectively, so the effectiveness and outcome of the educational presentation could be measured. The biggest barrier for the educational presentation was the time limitation. Twenty minutes seemed too short to present due to the complexity and sensitivity of the topic. However, the PCPs and MAs were attentive and remained interested during the presentation. When discussing that approximately 75% of PCPs are not aware if their patients have an AD and presenting the MA's role that could improve this statistic, the MAs seemed to be receptive. Additionally, although PCPs expressed their discomfort in having ACP and AD discussions, they were encouraged by the financial compensation for time spent counseling patients regarding ACP and ADs. One month after the presentation, coders for the facility were asked to collect the ACP and AD specific CPT code usage for before and after the educational presentation. Objective 4. Disseminate the outcome of the project to a larger audience The outcome of the project was presented to the clinical site and was presented to Salt Lake City Aging Services. Although ACP and ADs have increasingly become a public health issue and is receiving political attention, there is a lack of knowledge and utilization at the local health department level. Currently, when older adults contact the agency regarding ACP and ADVANCE CARE PLANNING 20 ADs, there is no one that can provide guidance or consultation on staff. The author contacted the local health department and disseminated the project outcome via a developed handout and inperson educational presentation. The effectiveness of the presentation was evaluated by pre- and post-education surveys and the results of the surveys were presented to the project chair. The author wrote an article summarizing the project objective and outcome and submitted it to the Rocky Mountain Geriatric Conference. The proof of submission was presented to the project chair (Appendix H). Results The IRB exemption for the project was obtained and the proof of the exemption was presented to the project chair (see appendix B). The author developed the educational presentation materials including algorithms for MAs and PCPs to facilitate ACP and AD discussions (see appendix C). Development of these materials was done through systematic literature review and consultations with the project chair and a content expert. The pre- and post-educational presentation questionnaires were dispensed before and after the presentation and the algorithms were distributed to MAs and PCPs respectively prior to the presentation during their staff meeting. A total six providers filled out the questionnaires including three physicians and three physician's assistants (n=6). Five providers reported that their patient population is mostly middle-aged adults (36 to 55 years), or older adults (65 and older). One provider reported that the patient population he or she sees is mostly younger adults (18 to 35 years), middle aged (36 to 55) and some older adults (65 and older). Through the pre- and post-educational surveys, the effectiveness of the educational module was evaluated by the difference in six components regarding ACP and ADs before and after the presentation. These include the knowledge of ACP and ADs of the PCPs, frequency of ADVANCE CARE PLANNING 21 ACP discussions, awareness of the topic, comfort level of PCP to have this discussion, motivation to have the ACP discussion, and familiarity of the ACP specific CPT codes. The pretest result showed that providers perceive that discussing ADs is important (mean 4 ± 1.09), yet there are two providers who have not discussed ADs with their patients in over a month. One provider responded that he or she discusses ADs at least once a month and two providers responded that they have AD discussions more than three times per month (overall mean 3.33 ± 1.97). There was also a wide range of comfort and knowledge regarding ACP and AD among providers (mean 3.67 ± 1.63 and 3± 1.27 respectively). All but one of the providers responded that they are somewhat or very motivated to discuss ADs with their patients (4 ± 1.67). None of the providers were aware of the CPT codes to bill for the time they spend on discussing ACP and ADs (1.00 ± 0.00). After the presentation, the post-survey showed an increase in mean results (see appendix F). Their perception of importance to discuss ADs increased (4.67 ± 0.82), they expressed that they will discuss ADs more often (4.67 ± 0.82), they felt their comfort and knowledge in discussing ADs increased (4.33 ± 1.03 and 4.33 ± 1.03 respectively) and their motivation to discuss ACP and ADs had slightly increased (4.33 ± 0.94). The providers' responses regarding applying the CPT codes was as follows: one provider responded that they will use them all the time, three providers answered that they will use them in some instances, and two providers responded that they do not foresee using the codes at all (mean 2.67 ± 1.51). The two providers who responded that they will not use these codes left comments that "I need to think about and process it" and "case managers are not using the codes." It is unexpected that those two providers were the ones who said that they feel very knowledgeable as well as comfortable having AD discussions with their patients. Regarding the algorithms, two providers felt they ADVANCE CARE PLANNING 22 were very helpful, three saw them as somewhat helpful, and one provider did not think it would be helpful for both the MA's and provider's algorithms (mean 3.33 ± 1.51 and 3.33 ± 1.37). Based on the Wilcoxon signed-rank test, provider's knowledge showed a statistically significant difference between pre- and post-presentation responses (p value of 0.046). Furthermore, the willingness to use the CPT codes increased after the presentation (p value of 0.059) which showed a trend toward a significant difference. Unfortunately, the PCPs' perception of significance, frequency of discussion, awareness, motivation, and comfort levels to discuss ACP and ADs did not yield either statistically or clinically important results (p value 0.157, 0.102, 0.157, and 0.317 respectively). Overall, the providers were very interested in the topic and learning about the CPT codes. A few providers spoke to the presenter in person conveying that the presentation was good, helpful and interesting. The medical director of the clinic asked for a copy of the educational PowerPoint slides. Additionally, a few MAs also expressed their interest in the project and related the project to their family members and themselves. One MA mentioned that she wanted to have an AD completed but her provider declined to discuss it with her because the provider felt she is too young to worry about those issues (she is forty-eight). Another MA also mentioned that she knows her mother has an AD but her provider is not aware that she has one. She added that she would bring a copy to her mother's provider so the provider can access it if it is needed in the future. In general, the author believes that the content of the project was delivered to the audience successfully. Unfortunately, there was no change in the CPT codes usage before and after the presentation. The data showed that none of the providers used the introduced CPT codes in the one month after the presentation. This is an unexpected result because the providers were ADVANCE CARE PLANNING 23 receptive and their response was positive during the presentation. A few factors might have influenced this result. First, one month may be too short to assess a change in culture or measure a meaningful outcome for the project. PCP's knowledge and willingness to discuss ACP and ADs might have increased. However, it takes time to adopt the recommendations and change their practice in real life. Second, even with increased knowledge and financial benefits, PCPs perceive that it is hard to incorporate ACP and AD discussions in their busy daily practice. Objective one was completed through thorough literature review and implementing a prelearning questionnaire to assess the providers' knowledge and comfort prior to the presentation. There was an increase in both knowledge and comfort in having discussions about ACP and ADs after the presentation. Objective two was successfully completed by developing the educational training materials including the algorithms to facilitate AD discussions between providers, MAs and their patients. These educational materials were developed by reviewing literature along with consulting the content expert and the project chair. The final product was submitted to the project chair for approval prior to the presentation. Objective three was completed by presenting the developed educational materials in a primary care setting during their staff meeting. The project effectiveness was measured by the developed pre- and post-presentation questionnaires, which were analyzed statistically. Objective four was completed by writing a summarizing abstract and submitting it to a professional conference. The project outcome was presented to the implementing clinic site and a local health department agency. Positive Unintended Consequences ADVANCE CARE PLANNING 24 Since the presentation, an increasing number of PCPs in the community are becoming aware of the ACP and AD specific CPT codes. The medical director of the presenting clinic introduced the DNP project in their providers' meeting and attending providers showed their interest in the project and the use of CPT codes in their practices. Although the project did not produce a positive outcome in a single month related to the CPT code usage difference, it is positive that an increasing number of PCPs are being made aware of these codes and encouraged by them. In addition, according to the coder's analysis, there has been an increase in use of ACP specific codes in other community clinics since the presentation. Hopefully, overtime, more and more of PCPs will feel comfortable and knowledgeable about ACP and ADs and there will be an increase in completing ADs in the long run. Future Recommendations There are a myriad of benefits in completing ADs, not only for individual patients but also their family members and our society as a whole. However, without providing proper support and applying more pressure by underlining the importance of having ACP discussions, the efforts to increase these discussions among PCPs might not be successful. They still might find having these discussions in primary care settings challenging or even impossible. Since January 2016, all providers are able to receive reimbursement for time spent on ACP and AD discussions. However, many PCPs seem unaware of these codes and that they can receive reimbursement. The pre-education survey showed that none of providers knew about these ACP specific CPT codes. These codes are intended to be a facilitator for encouraging ACP and AD discussions and need to be disseminated further among PCPs and to a much larger audience. In addition to providing financial compensation by utilizing the ACP specific codes, it might be beneficial if there are trained volunteers available at community clinics where PCPs can ADVANCE CARE PLANNING 25 refer their patients when they want detailed information about ADs or need help completing the forms. Another challenge is that not many providers feel comfortable or knowledgeable discussing ACP and ADs. This might be partially because very few providers have gone through a formal training to learn about ACP or end-of-life care. Facing the aging of the Baby Boomer generation, the need to have this discussion is increasing to align medical care based on a patient's wishes and preferences. It requires training, skills, and experience to develop proficiency. However, most schools, either medical or nursing, do not provide such training to their students so it mainly falls on the individual providers to learn and practice on their own. When weighing the potential benefits that ADs can bring to patients, family members, and society, it is very unfortunate that current and future providers do not receive formal education in ACP and end-of-life care decisions. Doctor of Nursing Practice Essentials Doctor of Nursing Practice (DNP) is one of the terminal degrees in nursing and has a goal of cultivating doctorate-prepared practitioners who are able to exhibit the highest level of leadership in practice as well as scientific examination in scholarly areas (American Association of Colleges of Nursing, 2006). This project is a quality improvement project and aims to increase the discussion of ACP and ADs in primary care settings and meet the following three DNP essentials. Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking DNP graduates must be equipped with an ability to work within organizational and system levels to improve the quality of care among individual patients, target populations or the ADVANCE CARE PLANNING 26 general public (AACN, 2006). There is an urgent need to increase discussions about ACP and ADs in primary care settings due to causes including growing medical advancements, rapidly increasing aging populations and an increase in the number of patients who suffer from chronic illnesses and die from them. PCPs are in a critical position to discuss ACP and ADs when patients are still physically and mentally healthy, yet many of them are not comfortable or motivated to discuss this issue. This project developed educational materials and algorithms intended to encourage ACP and AD discussions in primary care settings and deliver better health outcomes for individual patients as well as bring positive outcomes in healthcare spending. Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice Multiple research studies show that ACP and ADs have been shown to improve the quality of life and respect for patient's autonomy, as well as allow medical providers to practice beneficence and non-maleficence. The purpose of the project meets DNP Essential III, especially as stated "the scholar applies knowledge to solve a problem via the scholarship of application" which encompasses "translation of research into practice and the dissemination and integration of new knowledge" (AACN, 2006, p.4). The DNP project focuses on the translation of findings from studies (lack of awareness and discussion of ACP and ADs in primary care settings) into practice (finding a site and perform a study to increase ACP and ADs discussion) and the dissemination and integration of new knowledge. Essential VII: Clinical Prevention and Population Health for Improving the Nation's Health Clinical prevention includes risk reduction for patients and their families (AACN, 2006). ACP and ADs permits risk reduction for patients by allowing them to choose not to receive medical care that they do not want, hence, decreasing unnecessary suffering. ADs also have great ADVANCE CARE PLANNING 27 potential to reduce the risk of family conflicts and distress when they have to make end-of-life decisions for their loved ones if their loved ones are incapacitated. In addition, they also may decrease the ethical dilemma facing healthcare providers when treating patients who are unlikely to recover from their current state. If ADs are in place and the patient's wishes are known, this allows healthcare providers to provide care that aligns to the patient's wishes and priorities, therefore decreasing the risk of ethical conflicts and distress to the providers. Conclusions The purpose of the DNP project was to increase ACP and ADs discussion in primary care settings by promoting facilitators of such discussion. PCPs face many obstacles to having ACP discussions. They work in high-pressure environments where they have to treat patients with complicated medical conditions, yet provide high quality and safe care at the same time, and yield high productivity. Accomplishing these goals in short appointment times can be challenging and overwhelming. Although the importance of having ACP discussions cannot be emphasize enough, it is adding another task to their busy and intensive workloads. The educational module produced an increase of knowledge of ACP and introduced ACP specific codes that can be utilized by PCPs. The resulting trend toward a significant difference in PCP's wiliness to use CPT codes after the presentation is encouraging even though there was no actual CPT code usage in the one month following the presentation. The lack of CPT code usage may show that a one-month follow-up is not enough time to evaluate meaningful changes in PCP's practice. Moreover, the project showed that many PCPs are not aware of ACP specific CPT codes so there is a need to disseminate this information to a larger audience. There is no doubt that there is an absolute need to increase the ACP and AD discussions in primary care settings. Since PCPs struggle with competing priorities with limited time, it ADVANCE CARE PLANNING 28 would be beneficial to have a system in place to assist PCPs. This could be comprised of the education of PCPs on end-of-life care discussions, the availability of trained volunteers to assist with ACP discussions, and an order set that is embedded in the electronic medical system to remind PCPs to have these discussions. ADVANCE CARE PLANNING 29 References Ahia, C. L., & Blais, C. M. (2014). Primary Palliative Care for the General Internist: Integrating Goals of Care Discussions into the Outpatient Setting. The Ochsner Journal, 14(4), 704- 711. Allen, S.L., Davis, K.S., Rousseau, P.C., Iverson, P.J., Mauldin, P.D., & Moran, W.P. (2015). Advanced Care Directives: overcoming the obstacles. Journal of Graduate Medical Education, 7(1), 91-94. doi: http://dx.doi.org/10.4300/JGME-D-14-00145.1 American Association of Colleges of Nursing (2006). The essentials of doctoral education for advanced nursing practice. Washington, DC: Author Center for Disease Control and Prevention.gov. (2011). Advance Care Planning: Ensuring Your Wishes Are Known and Honored If You Are Unable to Speak for Yourself. Retrieved from https://www.cdc.gov/aging/pdf/advanced-care-planning-critical-issue-brief.pdf Center for Medicare and Medicaid Services .gov. (2016). Frequently Asked Questions about Billing the Physician Fee Schedule for Advance Care Planning Services. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-P ayment/PhysicianFeeSched/Downloads/FAQ-Advance-Care-Planning.pdf De Vleminck, A., Houttekier, D., Pardon, K., Deschepper, R., Van Audenhove, C., Vander Stichele, R., & Deliens, L. (2013). Barriers and facilitators for general practitioners to engage in advance care planning: A systematic review. Scandinavian Journal of Primary Health Care, 31(4), 215-226. http://doi.org/10.3109/02813432.2013.854590 Garrido, M. M., Balboni, T. A., Maciejewski, P. K., Bao, Y., & Prigerson, H. G. (2015). Quality of Life and Cost of Care at the End of Life: The Role of Advance Directives. Journal of Pain and Symptom Management, 49(5), 828-835. ADVANCE CARE PLANNING 30 http://doi.org/10.1016/j.jpainsymman.2014.09.015 Hinders, D. (2012). Advance directives: limitations to completion. American Journal of Hospice Palliative Medicine, 29(4), 286-289. doi: 10.1177/1049909111419293 Jolien, J.G., Moll van Charante, E.P., & Willems, D.L. (2015). Advance care planning in primary care, only for severely ill patients? A structured review. Family Practice, 32(1), 16-26. Kaiser Family Foundation.org. (2015). 10 FAQs: Medicare's Role in End-of-Life Care. Retrieved from http://kff.org/medicare/fact-sheet/10-faqs-medicares-role-in-end-of-lifecare/ Lutz, S., & Huitt, W. (2003). Information processing and memory: Theory and applications. Educational Psychology Interactive. Valdosta, GA: Valdosta State University. Retrieved from http://www.edpsycinteractive.org/papers/infoproc.pdf Pealrman, R.A. (2013). Advance Care Planning & Advance Directives. Retrieved from http://depts.washington.edu/bioethx/topics/adcare.html Wheatley, E.W., & Huntington, M.K. (2012). Advanced directives and code status documentation in an academic practice. Family Medicine, 44(8), 574-578. U.S. Department of Health & Human Services. (2008). Advance Directives and Advance Care Planning: Report to Congress. Retrieved from https://aspe.hhs.gov/basic-report/advancedirectives-and-advance-care-planning-report-congress#structure ADVANCE CARE PLANNING Appendix A DNP Project Proposal PowerPoint Presentation 31 ADVANCE CARE PLANNING 32 ADVANCE CARE PLANNING 33 ADVANCE CARE PLANNING 34 ADVANCE CARE PLANNING 35 ADVANCE CARE PLANNING 36 ADVANCE CARE PLANNING 37 ADVANCE CARE PLANNING 38 ADVANCE CARE PLANNING Appendix B Institutional Review Board Exemption 39 ADVANCE CARE PLANNING 40 ADVANCE CARE PLANNING Appendix C Advance Directive Educational PowerPoint Presentation 41 ADVANCE CARE PLANNING 42 ADVANCE CARE PLANNING 43 ADVANCE CARE PLANNING 44 ADVANCE CARE PLANNING 45 ADVANCE CARE PLANNING 46 ADVANCE CARE PLANNING 47 ADVANCE CARE PLANNING 48 ADVANCE CARE PLANNING 49 ADVANCE CARE PLANNING 50 ADVANCE CARE PLANNING 51 ADVANCE CARE PLANNING 52 ADVANCE CARE PLANNING 53 ADVANCE CARE PLANNING 54 ADVANCE CARE PLANNING 55 Appendix D Pre-education Survey ADVANCE CARE PLANNING 56 Pre-education Survey 1. What age group do you see most often in your practice? a. Mostly middle-aged adults (36 to 55 years) and older adults (65 years +) b. Mostly young (18 to 35 years), middle-aged (36 to 55 years) and some older adults (65 years +) c. Not seeing many older adults in my practice 2. Do you think it is important to talk about advance care planning and/or advance directives in your practice? a. Not important b. Somewhat important but not urgent c. Important and often talk with my patients about them 3. On average over a month, how many times have you talked about advance care planning (ACP) and/or advance directives (ADs) with your patients? a. Not at all b. More than once but less than three times c. More than three times 4. How comfortable are you discussing ACP and/or AD with your patients? a. Not comfortable b. Somewhat comfortable c. Very comfortable 5. How knowledgeable are you regarding ACP and/or ADs? a. Not knowledgeable b. Somewhat knowledgeable c. Very knowledgeable 6. When is a good time to initiate an advance care planning/advance directives discussion? a. When patients are newly diagnosed with chronic illnesses b. When patients are diagnosed with terminal illnesses c. When patients are experiencing exacerbations of their illnesses d. When there is a transition of care, such as discharge from a hospital or placement in a nursing home e. All of above 7. How motivated are you to discuss ACP/ADs? a. Not very motivated. I have other pressing issues to talk about with patients b. Somewhat motivated c. Very motivated. I see the usefulness of having ADs in place for my patients and their families. 8. Are you aware of the CPT codes 99497 and 99488 which can be used to bill the time spent on discussing ACP and ADs? ADVANCE CARE PLANNING a. Not aware b. Somewhat aware c. I know them and am using them already 57 ADVANCE CARE PLANNING 58 Appendix E Post-education Survey ADVANCE CARE PLANNING 59 Post-education Survey 1. Do you think it is important to talk about advance care planning and/or advance directives in your practice? a. Not important b. Somewhat important but not urgent c. Important and will talk with my patients about them after this presentation 2. How often do you think you will discuss ACP/ADs with your patients after this presentation over the next month? a. Not at all b. More than once but less than three times c. More than three times 3. After attending the presentation, how comfortable are you having a discussion about advance care planning/advance directives with your patients? a. Not comfortable b. Somewhat comfortable c. Comfortable 4. After the presentation, do you feel more knowledgeable discussing ACP/ADs? a. Not at all b. Somewhat feel more knowledgeable c. Very confident and knowledgeable 5. How motivated are you to discuss ACP/ADs after the presentation? a. Not very motivated. I have other pressing issues to talk about with patients b. Somewhat motivated c. Very motivated. I see usefulness of ADs in place for my patients and their family members 6. Do you think you can identify important moments to initiate advance care planning/advance directive discussion after the presentation? a. Not at all b. Able to identify some moments c. Able to identify most time 7. Do you find the presented algorithm for medical assistants helpful? a. Not so much b. Somewhat helpful c. Very helpful 8. How likely are you to incorporate the provider's algorithm into your practice? a. Unlikely b. Neutral c. Likely ADVANCE CARE PLANNING 9. How often do you think you would use CPT codes 99497 and 99498 in your practice? a. Not at all b. I may use them in some instances c. I think I will use them all the time 10. Do you have any suggestions or comments to improve the presented algorithms and contents? Thank you so much for you time and have a great day! 60 ADVANCE CARE PLANNING Appendix F Pre and Post-test Survey Results 61 ADVANCE CARE PLANNING 62 ADVANCE CARE PLANNING 63 ADVANCE CARE PLANNING 64 ADVANCE CARE PLANNING 65 Appendix G DNP Project Poster ADVANCE CARE PLANNING 66 ADVANCE CARE PLANNING Appendix H Rocky Mountain Geriatric Conference Abstract 67 ADVANCE CARE PLANNING 68 INCREASING ADVANCE CARE PLANNING AND ADVANCE DIRECTIVE DISCUSSIONS IN PRIMARY CARE SETTINGS Yeo Young Yoon, BSN, RN, DNP student Background: Advance care planning (ACP) and advance directives (ADs) involve an active medical decision process regarding one's end-of-life care in the event that a patient becomes incapacitated. The decision making process includes patients, family members as well as welltrained, motivated, knowledgeable health care providers who are willing to initiate such discussions and provide the necessary information to make informed decisions. Currently, there is a lack of discussions of ACP and ADs in primary care settings although the need to initiate ACP and AD discussions is increasing. Primary care providers (PCPs) are in a key position to initiate the discussion while patients are still physically and mentally well. An increasing number of people are suffering from chronic illnesses and this raises their risks of receiving invasive lifeprolonging measures, even if it is against their wishes. Purpose/Objectives: The goal of the doctor of nursing practice project was to increase advance directive discussions in primary care settings by increasing the knowledge and comfort level of primary care providers (PCPs). The first objective was to improve PCP's awareness and comfort levels regarding ACP and ADs. The second objective was to develop an educational module supported by the most current and evidence-based recommendations. The third objective was to implement an educational presentation in a primary care setting and evaluate the project effectiveness with pre- and post-educational presentation surveys. The fourth objective was to disseminate the outcome of the project to local health care departments and in a poster presentation. Methods: Via thorough literature review, obstacles and facilitators for ACP discussions were identified. Then, the educational module was developed based on evidence-based recommendations. Pre- and post-educational surveys were created to assess the presentation's effectiveness, including knowledge increase, comfort level, awareness, frequency of ACP and AD discussions, and the PCP's motivation to have these discussions. In addition, ACP specific CPT codes were introduced to facilitate AD discussions. The outcome was measured one month after the presentation by evaluating the CPT code usage. Results: The pre- and post-educational survey showed increased knowledge about ACP and ADs (3.00 ±1.27 pre-education, and 4.33 ± 1.03 post-education, Wilcoxon p value =0.046) and there is a trend toward a significant difference in PCP's willingness to use CPT codes after the presentation (1.00 ± 0.00 prior and 2.67 ± 1.51 after the presentation, Wilcoxon p= 0.059). However, one month after the presentation, there was no difference in actual CPT code usage by providers. Conclusions: The educational module produced an increase in knowledge of ACP and introduced ACP specific CPT codes that can be utilized by PCPs. The result of a trend toward a significant difference in PCP's willingness to use the CPT codes after the presentation is encouraging even though there was no actual CPT code usage in the one month following the presentation. The lack of CPT code usage may show that a one-month follow-up is not enough time to evaluate meaningful changes in PCP's practice. Moreover, the project showed that many PCPs are not aware of the ACP specific CPT codes so there is a need to disseminate this information to a larger audience.