Feasibility and Effectiveness of Virtual Group Advance Care Planning Visits During the COVID-19 Pandemic

Abstract

Background

The COVID-19 pandemic necessitated the transition from in person to virtual advance care planning (ACP) engagement efforts. This pilot initiative evaluated virtual group visits (GVs) and in-person GVs for ACP to determine their feasibility and effectiveness.

Methods

Participants included patients in a Geriatric Medicine clinic who were referred by their primary care physician to an ACP GVs intervention. The ACP GVs had 2 sessions, led by clinicians with ACP expertise who facilitated a discussion on patients’ values, goals, and preferences. Participants were provided with technical assistance to support use of the virtual platform. Evaluation included an ACP readiness survey, post-session feedback, GV observations, and electronic health record review at baseline and a 6 month follow-up for goals of care documentation and advance directives.

Results

Seventy patients attended 46 ACP GVs from August 2019 to February 2022, including 16 in-person GVs and 54 virtual GVs. At a 6 month follow-up, for virtual GVs participants (n = 54), goals of care documentation increased from 31% to 93%, and advance directives increased from 22% to 30%. For in-person GVs participants (n = 16), goals of care documentation increased from 25% to 100%, and advance directives increased from 69% to 75%. All surveyed patients in both formats would recommend ACP GVs.

Conclusion

ACP GVs are feasible and effective for supporting ACP, demonstrating an increase in both goals of care conversations and advance directives completion.

Keywords

advance care planning group medical visits shared medical appointments telehealth goals of care conversations COVID-19

Introduction

Advance care planning (ACP) is recognized as a process of preparing people and surrogate decision-makers for communication and medical decision-making.^1-3 The concept of ACP has evolved into a holistic process over the life course that includes both in-the-moment and advanced decisions at every life stage.⁴ Given the importance of implementing effective ACP interventions across the lifespan, primary care and ambulatory settings represent important opportunities to engage patients in the ACP process. Patients who have engaged in the ACP process have experienced higher goal-concordant care, improved quality of life, higher satisfaction with medical care, and eased burden of decision-making for families.^5,6 Despite these advantages, many older adults do not take part in these conversations.

The Engaging in Advance Care Planning Talks (ENACT) Group Medical Visits for ACP has been shown to be an effective person-centered model, increasing older adult readiness to engage in ACP conversations and ACP documentation.⁷ This ACP GVs intervention is based on Collaborative Learning Theory, which posits that: (1) learning is a social experience, (2) learners have diverse experiences and learning styles, and (3) learning includes the individual’s experiences alongside factual knowledge (ie, medical expertise).⁷ The first of the 2-session GV format focuses on sharing personal experiences, consideration of personal values, and the role of surrogate decision makers. The second session focuses on challenges and questions from the first session and learning how to talk to a physician about medical decision making in the setting of serious illness. The ENACT GVs intervention was implemented as in-person GVs in a geriatric clinic and found to increase ACP outcomes including choosing a decision maker, completion of ACP documents, and ACP engagement.⁷

Although telehealth approaches were not widespread prior to the COVID-19 pandemic, the COVID-19 pandemic necessitated the rapid transition from in person to virtual care. ACP engagement interventions became an important focus across health systems, including during hospitalizations,⁸ emergency department visits,⁹ and through the patient portal.^8,10 Thus, although virtual GVs for ACP in older adults had not been previously studied, the increased use of telehealth and the need for ACP engagement suggested the need for a virtual ACP GVs intervention. Past studies have shown virtual GVs to be just as effective as in-person GVs for other medical care needs like diabetes mellitus GVs, Well-Child Visits, or fall-prevention workshops.^7,11,12 This multi-year evaluation of a geriatric clinic ACP GVs initiative aimed to evaluate virtual GVs and in person GVs to determine their feasibility and effectiveness.

Methods

Setting and Population

The Geriatric Medicine Clinic at UCSD Health is staffed by geriatricians who care for more than 2600 patients aged 65 years and older per year. The average age of patients in the clinic is 81 years old, with 74% white, 8% Hispanic, and 39% male. The study included patients who were referred to in-person GVs between August 2019 and Feb 2020 and to virtual GVs between May 2020 and February 2022. The study was approved by the UCSD IRB as an exempt study.

Intervention: In-Person and Virtual Group Visits (GVs)

The ENACT GVs intervention was implemented as in-person GVs prior to March 2020 and as virtual GVs, starting in May 2020. Both visit formats invited a group of participants aged 65 years and older to participate in 2 group sessions that are each 2 hours long and 1 month apart. As described, the group facilitation focused on a discussion with interaction among patients about ACP topics.¹¹ The first ACP session focused on sharing personal experiences about ACP, consideration of personal values, and choosing and understanding the role of surrogate decision makers. The second session focused on follow up of ACP topics discussed in the first session and learning how to talk to a physician about end-of-life care. Participants were encouraged to complete a legal medical durable power of attorney form (MDPOA), or verbally choose a medical proxy if they were not yet ready to provide a written one. Family members were welcome and encouraged to attend with the patient, which was common for cognitively impaired attendees. Patients from both ACP GVs formats were encouraged to bring copies of preexisting or new advance directive documents or out-of-hospital orders to be scanned into the EHR the next time they came to the clinic.

Table 1 outlines key differences between in-person GVs and virtual GVs for ACP. Namely, in the virtual setting, volunteers called participants prior to the visit to familiarize them with Zoom technology (using chat, unmuting, video cameras, etc.) and to conduct pre-visit surveys to assess a patient’s confidence and willingness to engage with ACP discussions and ACP documentation. Additionally, virtual GVs participants were mailed ACP information ahead of the appointment, namely the GoWish Game,¹³ Prepare for your Care Advance Directive,¹⁴ a Physician Orders for Life-Sustaining Treatment (POLST) – California POLST form,¹ an ACP engagement Goals-setting worksheet to help patients choose a next step in the ACP process, and a wallet card for patients to list their ACP information.

Table 1.

ACP Group Visits Intervention: Key Differences in Content and Context of In-Person Group Visits Versus Virtual Group Visits.

Intervention Components	In-Person Group Visits	Virtual Group Visits
Structure	Account for time to check in 1 patient at a time at front desk and walk over to conference room	Simultaneous patient check ins, no time needed to walk over to conference room
Learning Tools	Folders, note paper, pens, video projector, white erase board, water, snacks provided at visit	Participants need their own computer/device and internet access
Advance care planning resources	Advance directives, Go wish game, conversation guide, ACP Goal Sheet can be provided at visit	Resources mailed out prior to visit (or sent as attachment via EHR if patient able to download and print)
Facilitator considerations	Location barriers to availability of 2 disciplines (a physician and social worker) on day of visit	Easier for 2 different disciplines to attend on day of visit
Group dynamics	More interactions and side conversations among participants. Bonds between participants, such as exchange of contact information after visit	More interactions and side conversations of participants with family or friends at home. Fewer bonds between participants
Goal setting	Able to collect participant ACP Goal Sheet	Unable to easily collect each participant ACP Goal Sheet

Context	In-Person group visits	Virtual group visits
Recruitment	Need to ensure comfort with clinic location; how to get to conference room	Need to ensure comfort with virtual platform; how to access and use
Documentation and billing	No telemedicine consent required. Use only ACP billing codes	Telemedicine consent may be required. Use virtual billing codes with ACP billing codes.
Environment	Need reserved ADA accessible conference room within clinic	Patient’s home, including internet connectivity and virtual platform access

Implementation Strategy

All patients in the geriatric medicine clinic were eligible for referral and primary care providers were asked to refer any English or Spanish-speaking patients who they felt would benefit from a facilitated discussion with their peers about ACP. From August 2019 to November 2020, participants were also referred to ACP GVs by flyers posted in clinic exam rooms or given to them at clinic appointments if they did not already have an advance directive on file. These flyers contained a phone number with instructions for participants to call to schedule. In December 2020, an EHR-based referral order was developed to enable primary care physicians to directly refer patients. Clinic administrative assistants utilized an EHR referral work queue to call and schedule patients for the GVs sessions, send appointment information via the patient messaging portal, and send patient materials via mail.

A large part of the implementation strategy was conducted by volunteers. The volunteers, mainly University of California at San Diego undergraduate students, did the UCSD health system volunteer training, as well as more specific training in palliative care (i.e. filling out their own advanced directive, becoming Communication and Advance Care Planning certified, reading papers, etc.). In this flow, volunteers called referred patients to confirm interest and conducted pre-visit surveys. They also ensured participants were prepared with the proper zoom link, zoom instructions, and reference materials received via mail. Clinic staff and volunteers were present to provide support, as well as take notes on each participant’s contributions to the discussion.

A physician facilitated all the workshops. Though it was originally planned for a social worker to also be present, there were only 3 sessions total in which a social worker was able to attend. The workshops as well were billed using ACP and/or Virtual Billing codes.

The interdisciplinary team, including geriatricians, nurses, administrative assistants, and student volunteers, met on a biweekly basis to coordinate upcoming roles and troubleshoot any issues.

Evaluation

All GVs were evaluated using the RE-AIM framework: Reach (percent of potentially eligible participants who attended a visit), Effectiveness (primary outcome of EHR-based clinical goals of care conversation note; secondary outcome of advance directives in EHR), Adoption (proportion of geriatricians who referred patients), Implementation (acceptability and participant feedback).¹⁵ Maintenance was not evaluated. Referrals and attendance were tracked using a secure REDCap database. Patient demographics were collected from the EHR. Patient-level ACP data, which includes goals of care conversation and advanced directives, was from August 2019 to February 2022, including baseline prior to participating in an ACP GV and 6 month follow-up after participating in an ACP GV. With the continuation of virtual GVs for ACP throughout 2022, participant feedback on feasibility continued after February 2022.

All session attendees completed post-session evaluations to assess the ACP GVs’ acceptability using a 5-point Likert scale and a question with a free text response.¹¹ The survey included 7 statements such as (1) The group visit setting is better for talking about ACP than a normal visit, (2) The group visit gave me useful information, (3) I felt comfortable talking about ACP with other people in the group, (4) Talking with other people about ACP was helpful, (5) I feel the group visit addressed my specific concerns, (6) I feel able to discuss ACP with my regular healthcare provider, and (7) I would recommend these group visit sessions to a friend. The eighth question was a free-response question where participants could provide feedback about the session in general and regarding the virtual format (“Please let us know how it worked for you. What went well? What didn’t go well?”). Participant feedback was recorded verbatim. The free-text responses were read by 2 research team members and groups according to themes related to implementation of the group visits. Exemplar quotations of participant feedback are presented.

Volunteers did emphasize post-session evaluations, however patient participation in these evaluations was a consistent challenge. So, volunteers began conducting post-session evaluations at the end of each visit after the main information had been given to reduce the need for follow-up calls post-visit.

The ACP GVs implementation team conducted post-session debriefing. ACP GVs facilitators shared notes on unsolicited patient comments during the GVs and captured immediate impressions from group facilitators (volunteers) regarding the session, namely notable characteristics, barriers or limitations to patient engagement and areas for improvement.

Results

Reach

There were 16 participants for the in-person GVs over 4 cohorts (conducted over a 6-month time). They had a mean age of 77.4 years old and were 50% male and 94% white. For the virtual GVs, there were 54 participants over 20 cohorts (conducted over a 21 month time). These participants had a mean age of 77.3 years old and were 57% male and 63% white. Additional patient demographics are shown in Table 2.

Table 2.

Demographics of ACP Group Visits Participants.

Characteristic	In-Person Group Visits (n = 16), n (%)	Virtual Group Visits (n = 54), n (%)
Age (yrs, mean)	77.4	77.3
Gender
Male	50 (8)	57.4 (31)
Female	37.5 (6)	35.2 (19)
Not identified	12.5 (2)	7.4 (4)
Race
White	93.8 (15)	62.9 (34)
Asian	6.25 (1)	20.4 (11)
Black/African-American	0	2.5 (1)
Other race/mixed race	0	15.8 (8)
Ethnic group
Hispanic	0	13 (7)
Non-Hispanic	100	81.5 (44)
Unknown/Not specified	0	5.5 (3)
Religion
Catholic	25 (4)	22.2 (12)
Christian	(3)	9.3 (5)
Jewish	12.5 (2)	7.4 (4)
Buddhist	0	3.7 (2)
Hindu	0	1.8 (1)
Muslim	0	1.8 (1)
None	18.75 (3)	24.1 (13)
Not specified	12.5 (2)	5.5 (3)
Protestant	0	16.7 (9)
Religious Science	6.25 (1)	0
Atheist	0	1.8 (1)
Other	6.25 (1)	5.56 (3)
Sexual orientation
Straight (not lesbian or gay)	68.8 (11)	70.4 (38)
Lesbian or gay	(0)	1.8 (1)
Not identified/chose not to disclose	31.25 (5)	27.8 (15)
Preferred language
English	100	92.6 (50)
Farsi	0	1.8 (1)
Spanish	0	5.5 (3)

Of the 344 patients who were referred to ACP GVs in the EHR since its inception in December 2020, 17 participants attended. Thus, 1 assessment of reach, based on electronic referrals was 17 of 344 (4.9%). All other participants were recruited from study flyers given or seen by participants in the exam room.

While the goal for both visit types was 8 participants per session, actual group sizes ranged from 2-8 patients due to cancellations and no-shows. With the two-session visit format, the retention rate for the second session was 64% for in-person GVs and 48% for virtual GVs.

Effectiveness

The primary outcome of ACP GVs was goals of care (GOC) conversations. Prior to group visits for ACP, only 25% of the in-person GV group and 31% of the virtual GV group had documented GOC conversations with their primary care provider. GOC conversations for this study were defined as clinician documentation in a designated EHR note type discussing the patient’s verbal expression of values, preferences, hopes and fears regarding ACP. Participating in an in-person GV led to a higher rate of GOC conversations, 100% (in-person) vs 93% (virtual) at 6-month follow up, as seen in Table 3.

Table 3.

Effectiveness of In-Person Group Visits vs Virtual Group Visits on ACP Outcomes.

	Baseline		6 month after ACP GVs
	Goals of Care Conversation	Advance Directives	Goals of Care Conversation	Advance Directives
In-person GVs	4/16 (25%)	11/16 (69%)	16/16 (100%)	12/16 (75%)
Virtual GVs	17/54 (31%)	12/54 (22%)	50/54 (93%)	16/54 (30%)

Adoption

As a measure of adoption of virtual GVs for ACP, 5 of the 6 geriatricians in the clinic had a patient who participated in the virtual GVs. In addition, all of the Medical Assistants (2), LVNs (2), and RNs (1) demonstrated participation in referrals as evidenced by documentation in the EHR.

Implementation

As a measure of implementation, participants’ perspectives on acceptability of the in-person GV format vs the virtual GV are shown in Supplemental Figure 1. The post-session evaluation assessed the participants’ levels of agreement with 7 statements concerning the acceptability of the ACP GVs. Supplemental Figure 1 reflects the patient responses that indicated “5: Strongly Agree” to the evaluation prompts. (In-person GVs: n = 16; Virtual GVs: n = 54).

Similarly, qualitative participant feedback was collected to assess the acceptability of the virtual group ACP format, as seen in Table 4. Notable feedback included virtual GVs being more accessible due to eliminating the need for traveling for visits. Participants also remarked how the virtual format alleviated some barriers for in-person visits, such as transportation, disability access/homebound status, social distancing during the pandemic, convenience of remaining at home for discussion of sensitive topics, and the ability of loved ones to participate from out-of-state.

Table 4.

Participant Feedback Related to Virtual Group Visits.

Domain	Example Feedback
Distance	Patients who attended from an out-of-state location (Illinois) discussed that the virtual format is “great” because otherwise, they would not have been able to attend an in-person visit. They do not think there would be a big difference if everyone had been able to “conveniently attend an in-person meeting”
Distance	Patient discussed that virtual visits are “more accessible to people” and that they “[wouldn’t] have to drive long distance[s]” to attend
Accessibility	Patient discussed that the virtual visits were “very helpful” because she is handicapped/major fall risk. Because the visit was conducted virtually, they were able to join and participate
Conversation flow	Patient said that they “had no problem with zoom. I Think group sessions are better than one-on-one discussions. It helps to find out what other people think”
Conversation flow	Patient said “it was very effective for me. I am more of a thinker, I don’t like to speak very much, but it was helpful for me to watch others talk about it. Liked seeing other people and being not alone. The zoom setting was really wonderful, more pleasant and easier than taking it by myself. I liked that I heard about what treatments would be happening in the ER. It is so much better than otherwise. Really appreciate having the presentation and Dr. Yourman giving her time. Also, the pamphlet was really helpful”
Comfortability and convenience	Patient stated that there was “less tension” when the visit was conducted online [via zoom] vs being in a doctor’s office and trying to ease into being comfortable over the course of the appointment. Patient mentioned that Dr. Yourman “put everyone at ease”. Additionally, patient said that due to the virtual format, she was able to spend more time speaking with the doctor instead of being cut off within 15 minutes in a traditional in-person appointment
	Patient discussed that it would have been “tougher in person because we would have to wear a mask and it would long and uncomfortable”. Patient mentioned that it was “nice to be able to grab a drink and be in the comfort of her home”
	Patient said that the virtual visit was “outstanding” and it was “convenient and interactive”

Using a telehealth platform also provided additional advantages of virtual technology (such as mute/unmute and start/stop video) allowing participants to determine the level of participation with which they were comfortable. Furthermore, features such as screen-sharing, text chat, and document sharing, allowed participants to send questions and interact with 1 another, group facilitators to present slides, and volunteers to address questions or concerns privately, send forms, links, or reference material via the chat feature throughout the session.

Over the implementation period, including the need for an unplanned transition to virtual GVs due to the COVID-19 pandemic, several challenges and resulting adaptations for virtual GVs were identified (Table 5). The main considerations involved visit facilitation, accessibility, and group dynamics. Strengths and weaknesses of both formats were captured by team members through debriefing forms as well as by patients in post-session evaluations. The most common challenge that Virtual Group ACP staff and volunteers encountered was technical difficulties on Zoom. This problem was addressed by having volunteers call patients 1 week prior to the visit to guide them through common Zoom practices (muting/unmuting, camera on/off, chat, etc.). Another common issue was a varied level of patient participation, as the virtual format presented difficulties for some to navigate, especially those with hearing and/or vision loss. Intermittent participation prompts (specifically addressing people for example) from the facilitator and closed captioning helped to ensure that all patients were engaged for the duration of the visit.

Table 5.

Adaptations for Virtual Group Visits Implementation Challenges.

Topic	Challenge	Solution
Mailed forms	Patients were either missing mailed forms or they were sent in the wrong language	• Coordinate with clinic and volunteers to ensure forms are mailed at least 2 weeks prior to the visit
		• Volunteers will confirm that patients have received necessary forms during the pre-visit calls. Any missing or wrong forms will be reported to clinic to be mailed or sent over email
		• Presentation slides can also show the forms during the visit
Length of visit	Some patients mentioned the visit was too long	• Present information up front and then open the floor for discussion
Length of visit	Some patients mentioned the visit was too long	• During the pre-visit call, volunteers will mention the duration of the visit. They also mention that patients can mute/stop video to take breaks and/or sign off early if needed
Participation of patient	Some patients did not participate/varied levels of participation. Some participants had cognitive impairment, hearing loss, decreased vision, decreased comfort with virtual platform, or preferred to listen and observe as opposed to speak	• Intermittent participation prompts from the facilitator
		• For hearing loss, ensure patients know how to amplify volume, use closed captioning feature on zoom
		• For decreased vision, ensure >=size 14 font for all mailed and online materials
		• For cognitive impairment, presence of support person to provide further explanation after visit, as well as 1:1 time offered by provider after the visit
Participation of support person	Out-of-state or working support persons unable to attend in-person visits	• Using a publicly available encrypted platform will allow participation of out-of-state or working support persons
Technical difficulties	Wrong zoom link shared	• Volunteers call patients 1 week in advance to the visit to guide them through using. Zoom and ensuring that correct zoom links have been shared
	Patient could not see shared content or hear the host	• Volunteers call patient privately to guide them through technical difficulties
	Patient did not stay muted	• Volunteers have host privilege to mute patients with background noise to minimize distractions
	Switching tabs and stopping screen share to do so constantly maximized screens for attendees and was a distraction	• All tabs pre-opened prior to the visit so that screen could constantly be shared
		• Use zoom feature to share only portion of screen and maintains privacy of host’s screen
Volunteers	Volunteer names were not clearly labeled	• Volunteers rename their zoom name to “first name last name (volunteer)” format
	Patients did not know who to ask for help	• Rotate volunteers, 2 volunteers per session
	Too many volunteers per visit	• Rotate volunteers, 2 volunteers per session

Discussion

This study demonstrates feasibility, acceptability, and increased ACP outcomes through adapting an ACP GVs intervention to a virtual GVs format. The virtual GVs were effective at ACP engagement, increasing GOC conversations from 31% to 93% and completion of advance directives from 22% to 30% of virtual GVs participants. The prevailing participant feedback received indicated the acceptability of the virtual format over the in-person format.

Several considerations must be made to the implementation and sustainability of ACP virtual GVs. One consideration is that patients may have differential access to technology based on socioeconomic status and/or technological know-how. This study had a homogenous population that was predominantly older, white men, and the results may differ with a more diverse participant base. No data was collected on educational level, which could play a role in having these types of conversations. Another limitation is that virtual visits may not be ideal or possible for those with hearing or visual impairments, though in some cases the use of “closed captioning” features in virtual platforms can be helpful for older adults hearing impairment. Furthermore, a barrier may be the availability of volunteers or clinic team members needed for the logistical component of these virtual visits: mailing materials, outreach calls prior to group visits, post-visit calls, and telehealth technology troubleshooting. Finally, billing for GVs is not intuitive and represents a deviation from clinician protocols for individual patient visits, a potential barrier for clinician participation.

Reach and recruitment in ACP GVs were limited in our study, as demonstrated by the relatively lower 4.9% participation rate of referred patients relative to other studies on ACP GV. It is possible that the time commitment (2 2-hour sessions) may have been a deterrent for this particular ACP intervention, or that more broadly, engaging patients in ACP conversations remains challenging¹⁶ and may relate to underlying fear and discomfort around serious illness discussions, lack of knowledge and awareness, and cultural and language barriers. However, challenges in engaging patients in ACP are not unique to GVs and there are many ways this challenge could be addressed in future studies, including by increasing clinician education and engagement around ACP, using patient testimonials, and other materials that are often used to attract patients and families to a behavioral intervention (e.g., food, posters, patient facing MyChart options, etc.). In addition, due to COVID-19 preclusion of in-person GV, relatively few patients participated in the in-person GV compared to virtual GV, thereby limiting any conclusions that can be drawn regarding differences between in-person vs virtual GV reach and recruitment.

An interesting follow up study, and thus limitation of ours, is looking at the comparison of ACP compliance with those who attended GV and those who did not. Because this study did not collect data from patients who did not attend ACP GV, we are unable to provide a comparison.

The study results have promising implications for the applicability of the virtual group format for other discussion-based health education beyond advanced care planning. The use of volunteers also demonstrates that expanding the definition of who comprises a healthcare team can alleviate much of the administrative burden and cost to make group visits a feasible way to deliver various health education topics. Other interdisciplinary team members can include administrative assistants, medical assistants, nurses, volunteers, social workers, and case managers.

In conclusion, virtual group visits for advance care planning were demonstrated in this study to be effective and feasible in our post-pandemic world. There is a plan in place to restart Group ACP once a new facilitator is found. In this coming time, further tests of change in the process of continuous quality improvement will be required in order to improve reach and effectiveness of Group ACP.

Supplemental Material

Supplemental Material - Feasibility and Effectiveness of Virtual Group Advance Care Planning Visits During the COVID-19 Pandemic

Supplemental Material for Feasibility and Effectiveness of Virtual Group Advance Care Planning Visits During the COVID-19 Pandemic by Lindsey Yourman, Alina Pollner , Jasmine Khatibi, Vanessa Ramos, Vaishnavi Melkote, Aoibhin O’Gorman3 , Erika Begler, and Hillary D. Lum in American Journal of Hospice and Palliative Medicine®.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Dr. Lum is Supported in Part by the National Institute on Aging of the National Institutes of Health under Award Number R01AG066804. The Content is Solely the Responsibility of the Authors and does not Necessarily Represent the Official Views of the National Institutes of Health.

ORCID iDs

Lindsey Yourman

Alina Pollner

Vaishnavi Melkote

Aoibhin O’Gorman

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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