Publication Date
2025
Document Type
Dissertation/Thesis
First Advisor
Coulter, Katherine
Second Advisor
Rosso, Elizabeth
Degree Name
DNP (Doctor of Nursing Practice)
Department
School of Nursing
Abstract
Abstract
Background: Advance Directives (ADs) support patient-centered care by documenting preferences for future medical treatment. While the Centers for Medicare & Medicaid Services (CMS) incentivizes AD documentation through billing codes, national adoption remains low.
Local Problem: A rural Northern Illinois primary care practice had electronic referral capabilities for ACP; however, referrals remained low and inconsistent during Medicare Annual Wellness Visits (AWVs), limiting opportunities for AD completion.
Methods: This quality improvement project targeted Medicare AWV patients without ADs documented in the electronic medical record (EMR). During a 10-week pre-intervention period, baseline data were collected. In the subsequent 10-week intervention phase, an EMR-based Our Practice Advisory (OPA) prompt was activated to guide best practices, reminding providers to initiate ACP, complete ADs, or place ACP referrals. The Doctor of Nursing Practice (DNP) student provided on-site education to support workflow integration and engagement.
Interventions: The EMR prompt guided the clinical care team and providers in introducing ACP, assessing interest, and referring eligible patients to the ACP team for AD documentation.
Results: Of 856 Medicare AWVs, 397 patients were AD OPA-eligible. ACP referrals increased from 27.4% to 43.1%, as confirmed by a chi-square test (χ2(1) = 13.37, p < .001). AD documentation rose from 0.2% to 9.3%, χ² (1) = 32.52, p < .001. A z test and Fisher’s exact test further supported statistical significance (p < .001).
Conclusions: The EMR prompt significantly improved ACP referrals and AD documentation. The intervention was low-cost, sustainable, and aligned with patient-centered care. With administrative support and CMS reimbursement, this model can be expanded across visit types and specialties.
Keywords: Advance Care Planning, Advance Directive, Electronic Medical Record, Quality Improvement, Medicare Annual Wellness Visit, Rural Primary Care, Nursing Practice, Patient-Centered Care
Recommended Citation
Meares, Annette L., "Optimizing Advance Care Planning: Leveraging an Electronic Medical Record Prompt to Impact Advance Directive Documentation" (2025). Doctor of Nursing Practice Scholarly Projects. 15.
https://huskiecommons.lib.niu.edu/nursinghealthstudies-doctornursingpractice/15
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