Date of Graduation

Spring 5-21-2021

Document Type


Degree Name

Doctor of Nursing Practice (DNP)




Family Nurse Practitioner

First Advisor

Dr. Karen Van Leuven


Background: Advance Care Planning (ACP) encompasses a multidisciplinary, collaborative process that allows patients to understand their health and make informed decisions in their treatment plans. Considering the COVID-19 pandemic and recent research, ACP is considered imperative for all patients. Evidence-based approaches include supplemental group sessions, case manager interventions, and provision of at-home resources. Within the pandemic, there has also been a rapid shift to telemedicine, restricting most ACP efforts. Therefore, the utilization of technology-based ACP resources and telemedicine is highly supported.

Purpose: This DNP project serves to assist an internal medicine practice located in Hawaii’s metropolitan area. Although the hospital system has previously made significant headway in ACP promotion, the COVID-19 pandemic has made primary providers even more aware of its significance. New workflows are needed to accommodate time restrictions, telehealth restrictions, and ACP reimbursement requirements.

Methods: The medical assistant (MA) provided patients a pre-visit survey during their appointment reminder. The survey included two video decision aids on ACP. During the appointment, the provider discussed the pre-visit survey and videos. After the visit, patients were given a survey to gauge changes in their ACP process and provide appropriate resources based on learning style and ACP needs. ACP discussion was documented and billed according to Centers for Medicare Service guidelines (CMS, 2020).

Results: 15 patients were enrolled in the study and completed the pre-visit survey. ACP engagement survey scores ranged from 3.9 to 4.5, indicating readiness for change. 1 patient completed the post-visit survey but showed no change in score. Annual ACP goal was met in 8 of 15 patients. 7 patients had a completed an AD, 2 of which during the project. Staff sited increased ACP awareness, increased time efficiency during visits, and overall satisfaction with project outcomes.

Conclusion: Advanced Care Planning is a relevant quality care measure that is essential to primary care regardless of patient health status. ACP can be promoted without introducing extraneous personnel or drastically altering MA and provider workflows. Patients and staff voice positive feedback to video decision aids and screening tools. However, opposition to technology is prominent in the elder patient population. In this, adequate planning, introduction, and implementation time is required to accommodate barriers to participation. Lastly, culturally sensitive and community-based resources are accessible and complementary to evidence-based methods.