A Telehealth Advance Care Planning Intervention for COVID-19 in New York City

The novel Coronavirus Disease 2019 (COVID-19) has highlighted the importance of advance care planning(ACP) for older patients who are most at risk of dying, and a critical need exists to optimize this process. ACPempowers patients to express their values and goals for care before they become too ill to do so. ACP alsoprepares patients, and their families, to make difficult decisions in real time when the moment arises. For olderpatients, COVID-19 may result in respiratory failure and high mortality rates. However, many older patientsmay prefer to avoid these interventions, especially if the mortality rate is high and death is experienced alone inthe hospital without family nearby. Motivated by the disproportionate risk to older patients from COVID-19 andthe higher mortality rates, primary care clinicians should engage all older patients with ACP to ensure theirpreferences are known and honored. Unfortunately, many clinicians have not been trained in ACP and patientsare unfamiliar with it. To address this gap, we have developed a Comprehensive Telehealth ACP Program for COVID-19that implements ACP routinely into medical care and responds to the present need for virtual communication.The ACP Program combines two well-tested, evidence-based, and complementary interventions: onlineclinician communication skills training and ACP patient video decision aids. The overall objective of thisapplication is to reduce the burden of COVID-19 and its consequences for an aging US population that mayprefer to forgo aggressive potentially ineffective interventions, and to die outside of the hospital setting. Toaccomplish this, we propose to conduct a Pre-Post trial using an open cohort design of a telehealth ACPProgram among older patients in the nation's COVID-19 epicenter, New York. We will train 250 primary careclinicians caring for 25,000 diverse patients over the age of 65 from the largest health care system in New York(Northwell Health). We will use Natural Language Processing to abstract our outcomes from the electronichealth records for patients. We hypothesize that a telehealth ACP Program of clinician serious illnesscommunication skills training combined with ACP videos will improve and sustain rates of ACP from the timethat the intervention is implemented compared to the time prior to the intervention. Clinician communication training and video decision support is a practical, evidence-based, andinnovative approach to uniformly provide robust ACP. Major strengths of this proposal are: the highlyexperienced team making this project feasible; the present infrastructure already embedded at NorthwellHealth, which has the largest number of COVID-19 patients in the US; and, the potential immediatedeployment of the intervention, if successful, across the country. This work holds the promise of improving thequality of care provided to millions of Americans during the COVID-19 pandemic.