Disease burden is higher in the United States than in comparable countries. The Patient Self Determination Act of 1990 requires healthcare facilities to provide Advance Care Planning (ACP) information to all Medicare patients. The healthcare staffs’ (n=7) commitment to 3-days of ACP training increase ACP rates in the primary care setting. The Medicare Incentive Program is the platform for this initiative. This quantitative project used a valid and reliable pre and posttest design that consisted of 27 items on a Likert-scale. A 3.5-month chart audit (n=91) was conducted to assess the completion rate. Descriptive statistics was used to describe the demographic data.

The results of the two-tailed Wilcoxon signed rank test were significant based on an alpha value of 0.05, V = 0.00, z = -2.37, p = .018. There was a significant increase in the post-readiness to change average scores. A Mann Whitney test was used to analyze the statistically significant difference between the averages in two ACP types and electronic health record documentation (EHR). Staff did not always code (Mdn = 0.00) but they documented in the EHR (Mdn =1.00; 512.00, p = 0.003). ACP discussion was performed 63% of the time during Annual Wellness Visits (AWV), and there was a 49% increase in the EHR documentation. Trained staff are key stakeholders in guiding ACP conversations. They understand the barriers, impact, and consequences related to the lack of advance directives.

As Baby Boomers age, the number of older homeless patients facing end of life is increasing. Homeless individuals die of the same diseases as their domiciled counterparts, but they have distinct barriers to equitable end-of-life care, such as lack of regular medical care, a higher likelihood of comorbid serious mental illness and substance abuse, alienation from potential healthcare proxies, and specific fears related to dying. Completion of an advance directive (AD) would address many of these barriers, as well as national goals of reducing medical costs associated with end of life care. A review of the literature indicates that homeless individuals, once educated on the purpose and significance of ADs, complete them at a higher rate than non-homeless people. Further, racial and ethnic disparities in document completion are minimized with educational interventions about an AD’s purpose.

King’s Theory of Goal Attainment provides the theoretical basis for the application of such an intervention in the setting of a medical respite center and a day resource center that both serve the homeless. Thirty-seven clients of the two sites and 14 staff members were administered a pre-and post-test measuring attitudes and knowledge relating to ADs on a Likert scale, resulting in an increase in knowledge about one of the two documents that traditionally comprise an AD, while not significantly affecting attitudes. Implications for practice include an inexpensive intervention that does not require a medically trained individual to deliver, enabling a broad application to a variety of settings with the goal of empowering a traditionally disenfranchised population to make health decisions related to the most vulnerable of life passages.

Early and effective end-of-life care are associated with increased quality of life for those patients who may be nearing the end-of-life (EOL). However, evidence suggests that most non-palliative healthcare providers lack the skills and confidence to initiate EOL conversations. Consequently, about 70% of Americans would prefer to die at home with their families, yet only 25% die according to their wishes (State of California Department of Justice, n.d). In alignment with the Peaceful End of Life Theory, the purpose of this evidence-based project is to increase primary healthcare providers’ level of skills and confidence in end-of-life discussions.

This project utilized a pre and post study design. A total of 11 participants were recruited using convenience sampling from three primary care clinics in Phoenix, Arizona. Due to the small sample size and assumption of a non-normal distribution of the data, Wilcoxon Signed Ranks test and Pearson correlation coefficient were used for statistical analysis. There were clinical and statistical significant improvements in the EOL knowledge of the participants after the implementation of the two-and-a-half-hour Serious Illness Care Program (Z = -2.950, p = .003) with a large effect size (r = -0.62).

The project evaluation also demonstrated that most participants deemed that the intervention was effective. A brief and systematic education session, such as the SICP can be utilized to improve non-palliative healthcare providers’ skills in having more and effective end-of-life conversations.