Effect of group community health worker–led advance care planning education on advance care planning documentation, satisfaction, palliative care, and hospice: Results from a randomized clinical trial.

Abstract

1521 Background: Advance Care Planning (ACP) is recommended for all patients with cancer yet engagement remains low due to multilevel barriers including limited clinician time, lack of adequate reimbursement, and workforce shortages. Our team demonstrated that one-on-one community health worker (CHW)-led education interventions can improve ACP documentation, satisfaction, and hospice use. Group CHW-led interventions may improve scale and spread, however, the effectiveness of such approaches compared to usual cancer care remains unknown. Methods: This prospective randomized clinical trial compared a 1-month CHW-led group ACP education intervention plus usual cancer care (intervention group) with usual cancer care alone (control group). Veterans newly diagnosed with solid tumor malignancies, 18 years of age or older, and planned to receive cancer care at one VA facility were eligible. All who verbally consented were randomized 1:1 to the intervention group or the control group. The intervention consisted of two 90-minute group sessions over 1-month post-randomization with 8-10 participants per group led by trained CHWs. The sessions included tailored education regarding ACP, surrogate decision-maker designation, and communication strategies with cancer clinical teams. Usual care included access to nurse navigators, social workers, palliative care and hospice teams, and ancillary support services. The primary outcome was ACP documentation (comprised of the VA Life Sustaining Treatment, VA Advance Directive, and Goals of Care documentation by the oncology clinician) in the electronic health record within 6-months after randomization. Secondary outcomes included satisfaction with care decision, palliative care use, and hospice use. Results: 65 patients were screened with 60 (92.3%) eligible of whom all 60 (100%) participated with 30 in each group. There were no withdrawals or participants lost to followup; 55 (91%) were male; 5 (8.3%) were female; median age was 79 years (IQR 67-86); 53 (88.3%) had stage 3 or 4 cancer; 9 (15%) reported ethnicity as Hispanic or Latino; 39 (65%) reported race as White; 12 (20%) Black; 3 (5%) American Indian; and 6 (10%) multiple races. At 6-months followup, intervention group participants had greater ACP documentation (30 (100%) versus 12 (40%)), strongly agreed that they were satisfied that care matched their preferences (27 (90%) versus 18 (66.7%)); no differences in palliative care use (3 (10%) versus 3 (10%)) and greater hospice use (15 (55.6%) versus 3 (10.0%)) than control group participants. Conclusions: This group CHW-led ACP education intervention improved ACP documentation, satisfaction, and hospice use at one VA. Group CHW-led ACP approaches may be a potentially scalable approach to address workforce shortages and effectively improve ACP. Clinical trial information: NCT06646614 .