A Portal-based Advance Care Planning Intervention Among Community-Dwelling Persons Living With Cognitive Impairment

NCT06509373 | Completed DMC

• 2 other identifiers: IRB001121435K23AG070234-03
• Study Type: interventional
• Target: 300
• Locations: 1 country
• Sites: 1

Brief Summary

The purpose of this research is to examine the feasibility of using a patient portal based advance care planning (ACP) tool to improve ACP discussions and documentation in persons living with cognitive impairment in outpatient primary care.

Conditions

Advanced Care Planning

Keywords

Advance Care Planning; Mild Cognitive Impairment; Dementia; Patient Portal

Outcome Measures

Primary Outcomes (2)

• Reach/Engagement

  Percentage of participants who open the advance care planning tool (ACPVoice) mychart message

  6 months post intervention

• Intervention Completion

  Percentage of participants who were sent the ACPVoice mychart message that complete the ACPVoice tool.

  6 months post intervention

Secondary Outcomes (6)

• Advance Care Planning Documentation Rates by Primary Care Providers

  12 months pre intervention

• Advance Care Planning Documentation Rates by Primary Care Providers

  6 months post intervention

• Advance Care Planning Billing Code Usage

  12 months pre intervention

• Advance Care Planning Billing Code Usage

  6 months post intervention

• Documented Designated Surrogate Decision Maker

  12 months pre intervention

Other Outcomes (9)

• Barrier to Adoption

  6 months during the implementation period and up to 6 months post the implementation period

• Quality of Advance Care Planning Documentation

  6 months during the implementation period and up to 6 months post the implementation period

• Participant Confidence related to PCP knowing what is important to them

  6 months during the implementation period and up to 6 months post the implementation period

Study Arms (2)

ACPVoice Intervention

EXPERIMENTAL

Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health , have a primary care physician at one of the participating sites, and have an active patient portal account.

Behavioral: Advance Care Planning Tool - ACPVoice

Standard of Care

ACTIVE COMPARATOR

Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health, have a primary care physician within the Atrium-Wake Forest Baptist Health Network, and have an active patient portal account.

Behavioral: Standard of Care for Advance Care Planning

Interventions

Advance Care Planning Tool - ACPVoice BEHAVIORAL

Eligible patients will be sent a secure MyChart message with a motivational message asking them to complete the advance care planning tool (ACPVoice) with their care partner/surrogate decision-maker or loved one before their upcoming primary care visit. The ACPVoice tool will be attached electronically to the mychart message. A reminder message will be sent to an non-responders with a different motivational message.

ACPVoice Intervention

Standard of Care for Advance Care Planning BEHAVIORAL

Patients will have access to the standardized advance care planning questionnaires readily available already within their mychart account which is part of standard of care.

Standard of Care

Eligibility Criteria

• Age: 65 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Older Adult (65+)

You may qualify if:

• Age 65 years old and older
• Diagnosis of recognized or probable mild cognitive impairment or mild dementia or elevated eRADAR score
• Completed visit with their primary care provider (PCP) within the past 12 months and have upcoming PCP visit in next 6 months
• Have an active patient portal account

You may not qualify if:

• Lives in a long-term care facility
• Severe vision impairment/blindness (as they need to be able to read portal messages)
• Enrolled in hospice
• Lacks decisional capacity as deemed by PCP

Sponsors & Collaborators

• Wake Forest University Health Sciences: lead
• National Institute on Aging (NIA): collaborator

Study Sites (1)

Wake Forest University Health Sciences

Winston-Salem, North Carolina, 27157, United States

Location

MeSH Terms

Conditions

Cognitive Dysfunction; Dementia

Interventions

Standard of Care; Advance Care Planning

Condition Hierarchy (Ancestors)

Cognition Disorders; Neurocognitive Disorders; Mental Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases

Intervention Hierarchy (Ancestors)

Quality Indicators, Health Care; Quality of Health Care; Health Services Administration; Health Care Quality, Access, and Evaluation; Patient Care Planning; Comprehensive Health Care; Patient Care Management

Study Officials

• Jennifer Gabbard, MD

  Wake Forest University Health Sciences

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: NON RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: SINGLE GROUP
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: July 12, 2024
• First Posted: July 19, 2024
• Study Start: August 19, 2024
• Primary Completion: June 27, 2025
• Study Completion: December 10, 2025
• Last Updated: February 27, 2026

Record last verified: 2025-12

Data Sharing

• IPD Sharing: Will not share

Locations

US (1)