Date of Graduation

Summer 8-12-2022

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone

First Advisor

Dr. Sara Horton-Deutsch


Problem: Advanced care planning or ACP, which is also called "Life Care Planning," empowers patients, helps them make better decisions, and encourages compassionate, person-centered care. It promotes patient autonomy and self-determination and is important for everyone, regardless of age or health, but it's especially important for older or sicker people. Even though LCP is important, it does not happen as often as it should. In January 2022, one integrated service area had only completed 11 percent of the LCP conversations with patients who would benefit from this service aligned with a criteria-based algorithm.

Context: To promote person centered care, In Northern California, an integrated health care system set up a regional team in July 2021. The Regional team of trained LCP Facilitators aims to augment LCP conversations in 16 service areas across Northern California, but can only do so if local service areas send them referrals. Clinic-based case managers can be used to generate more LCP referrals to the Regional CF team because they have a long-term, trusting relationship with medically complex patients.

Intervention: The Transitions Care Program (TCP) assists high-risk patients with complex medical and psychosocial requirements as they transition from the hospital to home. The intervention for this project was to provide education to the defined learners (TCP Case Managers) focusing only on the importance of LCP, how to appropriately identify eligible patients using the LCP registry and offer talking points on how to introduce LCP to their patients. This educational in-service training was conducted the 3rd week of May 2022.

Measures: The outcome measure aimed to increase the percentage of patients in the LCP registry who have had an LCP conversation from 11% to 25%. The process measure was percentage of LCP referrals sent to CF by clinic-based CMs after training, with a target of increasing to least 50% by the end of June 2022. The percentage of patients who declined to participate in LCP following CF outreach was defined as a balancing measure.

Results: Since the training, the number of LCP referrals from the local service area rose from 40 to 82, a 105 percent increase. Also, the number of people who declined or couldn't be reached decreased from 42.5 percent to 15.8 percent. Although the number of completed LCP conversations went up from 11% to 17% from January to May 2022, this increase can't be linked to the intervention because the training occurred in May.

Conclusion: LCP enables patient-centeredness by ensuring that care aligns with beliefs, goals, and preferences. To promote LCP, barriers need to be mitigated and enablers need to be strengthened. When LCP is executed properly, it helps patients, families, and the healthcare system. Any effort to improve Advance Care Planning (or LCP) is valuable; educational quality improvement projects need to support and reinforce this standard of personalized care management.


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