Overview: The goal of this study is to demonstrate the effectiveness of a home-based advance care planning (ACP) video intervention for improving ACP conversations, resuscitation preference documentation, hospice utilization, and reducing cost of care for patients with life-limiting illness receiving care in the home setting. Background: The number of patients living with serious chronic illness and receiving home-based care through Medicare's House Call Providers program is increasing. Often, these patients lack exposure to specialty palliative care and too frequently receive inpatient palliative care consultations late in the illness trajectory. A large portion of these inpatient specialty palliative care consults are focused exclusively to support ACP documentation, and addressing end-of-life (EOL) care needs for this population. Health care systems require evidence-based ap- proaches that promote these focused palliative care services at home while surmounting challenges such as palliative care workforce shortage. We have developed a video-assisted, home-based ACP intervention (Home- ACP) to improve patient-clinician communication, increase ACP documentation, and lead to more patient-cen- tered and less costly care at the EOL. Home-ACP combines two evidence-based features including 1) predictive analytics to identify patients with an advanced serious illness and a projected prognosis of one year or less; and 2) ACP video decision aid delivered by a nurse as part of Clover Health's House Call Provider program. Our prior work has shown the efficacy of ACP videos in several randomized trials, but have not examined their effect in the home setting. The video is available in 25 languages and scripted at a low literacy level. Research Plan: We propose to conduct a randomized clinical trial of the Home-ACP intervention versus usual care in 500 patients with life-limiting illness and a prognosis of one year or less, receiving home-based care. We will assess the effectiveness of the Home-ACP intervention for preferences for resuscitation, ACP documenta- tion, and hospice utilization. We will also compare patient-reported outcomes in a subset of 200 patients including ACP knowledge, confidence in future care, communication satisfaction, and decisional certainty. Lastly, we will compare the cost of care in the last year of life for patients receiving the Home-ACP intervention versus usual care. Environment: This project will be conducted with the support of the Clover Health House Call Providers pro- gram, which has the resources, infrastructure, and electronic health record capabilities to ensure the success of this trial. Patients will be recruited from 17 counties in New Jersey with substantial ethnic and racial diversity. The investigative research team has the expertise in developing and testing video decision aids and palliative care interventions in large multi-site national trials. Relevance of Research: This project will establish the foundation of a future implementation and dissemination pragmatic trial including tens of thousands of patients in House Call Provider programs across the country.
Despite limited access to specialty palliative care, there is a critical need to optimize advance care planning (ACP) and end-of-life (EOL) care for patients with chronic, life-limiting illness receiving home-based care. ACP video decision aids have shown promising efficacy for improving patient-clinician communication, increasing ACP documentation, and leading to more patient-centered and less costly care at the EOL, but they have not been tested in the home setting. This proposal seeks to assess the effectiveness of a home-based ACP video intervention (Home-ACP) for improving resuscitation preferences' documentation, ACP conversations, hospice utilization, and reducing costs of care in the last year of life for patients with chronic, life-limiting illness receiving home-based care.
