Disseminating a Digital ACP Platform (Our Care Wishes) to Hospitalized Patients
Condition: Hospitalism
Study type: Interventional

Summary: 
      Penn Medicine has created a novel, online, evidence-based advance care planning (ACP)
      platform through its Center for Health Care Innovation. The platform is called "Our Care
      Wishes" and utilizes a 'shopping-cart' approach to ACP, allowing users to name surrogate
      decision makers, make choices about quality of life and medical treatments, outline medical
      wishes and organ donation, and share preferences for their end of life experience. Our Care
      Wishes then creates an easy to read, updatable ACP document that can be electronically shared
      with loved ones and uploaded to a patient's electronic medical record in PennChart.

      It is believed that this platform may help to overcome engagement and infrastructure barriers
      previously identified in the literature regarding the completion of ACP documents. The
      intervention will consist of multi-channel information dissemination regarding Our Care
      Wishes to Hospital of the University of Pennsylvania patients admitted through two locations
      (the Emergency Department, Silverstein 1 Admission Office) and outpatients who are seen in
      Pre-Admission Testing (PAT). All patients visiting these two locations during the
      intervention phase will receive a paper handout with information regarding Our Care Wishes
      included in their customary admission folder packet. The registration representative (RR) at
      these three locations will provide a brief explanation of the site as they check the patients
      in, as well send the patients a direct link to the site for non-ED admits via email and text
      message.
    

Detailed description: 
      Registration representatives (RR) from Silverstein 1 Admission Office, the Emergency
      Department, and the Pre Admission Testing office will be administering the intervention at
      the three sites. The current workflow is for the RR to provide all new admits with an
      admission packet created by Guest Services and also ask ALL patients whether they have
      completed an Advance Directive as mandated by the Patient Self-Determination Act of 1991 with
      little attention paid to encouraging AD completion. During the control/baseline phase of this
      trial, this workflow will remain the same.

      During the intervention phase, a flyer describing the Our Care Wishes platform will be added
      to the back pocket of admission packets for patients being admitted via the Silverstein 1
      Admission Office and the Emergency Department and for patients being seen in the Pre
      Admission Testing office. The interventions will vary slightly between Silverstein 1/PAT and
      the Emergency Department given concern for limited bandwidth by RR in the ED setting.

      For patients admitted through Silverstein 1 and who visit PAT, they will present to the RR
      per usual and the RR will follow the current workflow. At the point where the RR asks the
      patient if they have an AD and if it is present, the RR will remind the patient of the
      importance of having a document that records their care wishes. The RR will then inform the
      patient that Penn has created a free, online resource called Our Care Wishes to help patients
      with Advance Care Planning. The platform allows patients to upload their wishes right into
      PennChart using their MyPennMedicine login. The RR will then show the flyer in the back
      pocket of the admission folder to the patient. For patients being admitted via Silverstein 1
      Admission Office and those being seen in the Pre Admission Testing office, the RR will then
      proceed to ask patients if they would like to be sent a link to Our Care Wishes by email or
      text. For those patients who respond affirmatively, the RR will ask for the preferred email
      or phone number and will then complete the necessary fields to refer on
      www.ourcarewishes.org/refer.

      For patients admitted through the Emergency Department, a weekly report will be created that
      generates a list of admissions during the prior week along with their active PennChart email
      address and date of death if applicable (maternal and child health will be excluded). The
      research coordinator will email non-deceased patients 7-14 days after their admission date.
      The email will be sent to patients with an email address in PennChart. The email will not
      include any personally identifiable information regarding the patient or mention of their
      recent admission/visit. The email will include high-level information regarding Our Care
      Wishes, effectively summarizing the information that the patient received in their admission
      folder and stating the value of ACP, along with a direct link to access Our Care Wishes.

      For this process, it is estimated that the RR will spend 60-90 seconds noting the presence of
      the handout in the admissions folder and sending the patient a direct link (for those that
      opt-in). Frequency of the intervention will be every patient admitted via Silverstein 1
      Admissions office and seen in Pre-Admission Testing during the intervention timeframe.

      Each week, a report will be constructed via EPIC reporting to identify the patients that are
      admitted via these offices during this timeframe. The report will be made available to only
      key personnel on this research study. The report will also include this information which is
      routinely collected during the course of a hospitalization:

        -  Demographics (date of birth, sex, etc.)

        -  Date of death (if recorded in the EHR)

        -  Place of death (if recorded in the EHR)

        -  Dates of hospitalization(s)

        -  Contact information (email address and mobile phone number)MRN

        -  HAR

        -  Name

        -  Unit admitted to

        -  Presence of AD in EHR

        -  Admission source (need ED and Silver 1)

        -  Outside hospital transfer? (exclude if yes)

        -  Mother/baby? (exclude if yes)

        -  PAT appointment date
    

Intervention name(s): Our Care Wishes
Intervention type(s): Behavioral
Intervention description(s): A flyer describing the Our Care Wishes platform will be added to the back pocket of admission packets for patients being admitted via the Silverstein 1 Admission Office and the Emergency Department and for patients being seen in the Pre Admission Testing office. Registration reps in these locations will inform all patients seen that Penn has created a free, online resource called Our Care Wishes to help patients with Advance Care Planning and ask if they would like to be sent a link to Our Care Wishes by email or text. For those patients who respond affirmatively, the rep will then complete the necessary fields to refer on www.ourcarewishes.org/refer.
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Intervention model description: The design is a stepped-wedge cluster design in which specific areas of the hospital will adopt the intervention, in sequence. All areas of the hospital will begin in the control phase. 12 weeks into the study period, the first "wedge" or area of the hospital will adopt the Our Care Wishes intervention, 4 weeks after, the next wedge will switch the control phase, the final wedge will adopt the intervention after that.
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: Advance care planning