Services Supporting Self-Direction
Publication Year
Study Type
Content Type
Peer Reviewed
Population
Outcome Type
Chronic Condition Choose up to 3
Services Supporting Self-Direction
Services supporting self-direction allow enrollees to have the responsibility for managing all aspects of healthcare delivery in a person-centered planning process; while such services are a non-primarily health related benefit, they may have a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee. Plans may provide services to assist in the establishment of decision-making authority for healthcare needs (e.g., power of attorney for health services) and/or may provide education such as financial literacy classes, technology education, and language classes. Interpreter services may also be provided to enrollees to facilitate encounters with healthcare providers. Plans may not include expenses for funerals as a covered benefit. Primarily health related education (e.g., Health Education, Medical Nutrition Therapy) that is consistent with existing guidance (see Chapter 4, section 30.3) for primarily health related supplemental benefits may be offered by an MA Plan as a supplemental benefit in PBP category B14c.
Linking Gap and Impact
2022|
Journal of Pain and Symptom Management|
Google Scholar|
https://doi.org/10.1016/j.jpainsymman.2022.02.049
Outcome type: Favorable
The study found numerous disparities in end of life care by race. White residents are more likely to complete advance directives compared to racial and ethnic minority residents. Black and Hispanic residents were less likely to convert from full care orders to do-not-resuscitate orders. Timely efforts are needed to improve NH end-of-life care by providing culturally competent training for NH staff that provide care in diverse NHs.
Systematic Review
Peer Reviewed
Age > 65
Linking Intervention and Impact
2020|
BMJ Supportive & Palliative Care|
PubMed|
33115830|
10.1136/bmjspcare-2020-002520
This study examines the use of advance care planning on place of death and utilization of life-sustaining treatments among patients in end-of-life care.
Outcome type: Favorable
The study found that patients with ACP were more likely to die at home and less likely to receive life-sustaining treatments during EOL care.
Prospective Cohort Study
Peer Reviewed
Age > 65
Linking Gap and Impact
2018|
Family Practice|
PubMed|
29140508|
10.1093/fampra/cmx113
Outcome type: Favorable
The study found that individuals with greater interaction with the healthcare system through hospitalization, multimorbidity, access to quality primary care and informal caregiving reported more advance care planning activities.
Other
Peer Reviewed
Age > 65
Linking Intervention and Impact
2024|
PEC Innovation|
PubMed|
38525314|
10.1016/j.pecinn.2024.100273
This is a systematic review analyzing the effectiveness of decision aids for end-of-life care.
Outcome type: Favorable
The majority of studies reported positive outcomes in reducing decisional conflict in end of life care especially when the decision aid intervention was used.
Systematic Review
Peer Reviewed
Age > 65
Linking Intervention and Impact
2018|
MDM Policy & Practice|
PubMed|
30288436|
10.1177/2381468317753127
This study evaluates the effect of an active choice intervention on advance directive completion.
Outcome type: Favorable
The intervention significantly increased the proportion of participants completing an advance directive without changing the choices in advance directive.
Randomized Controlled Trial
Peer Reviewed
Age > 65
Linking Gap and Impact
2016|
Journal of Palliative Medicine|
PubMed|
26840850|
10.1089/jpm.2015.0326
Outcome type: Favorable
The study found disparities in advance care planning, that black race is an independent predictor for advance directive possession. This association remains even after adjustment for other demographic variables, religious characteristics, and personal health values.
Other
Peer Reviewed
Age > 65
Linking Gap and Impact
2019|
Psychiatric Services|
PubMed|
PMC6718300|
10.1176/appi.ps.201800544
Outcome type: Favorable
Self-directed care interventions should address competence, autonomy, and relatedness needs in order to facilitate choices that people with serious mental illnesses make as they work toward achieving recovery goals.
Other
Peer Reviewed
Age > 65
Linking Intervention and Impact
2020|
Patient Education and Counseling|
PubMed|
31744701|
10.1016/j.pec.2019.10.005
This study evaluates the effect of a health literacy, chronic disease self-management and social support intervention for older people delivered by group videoconferencing into the home.
Outcome type: Favorable
The health literacy intervention indicates potential to improve social support and some health literacy factors in older people.
Other
Peer Reviewed
Age > 65
Linking Intervention and Impact
2014|
Health Affairs|
Google Scholar|
https://doi.org/10.1377/hlthaff.2013.1258
VIEW ARTICLE
PERMISSIONS
This study examines association between advance directives and nursing home stays and end-of-life care for patients with severe dementia
Outcome type: Favorable
The study found that having an advance directive in the form of a living will was associated with significantly less aggressive care at the end of life, compared to similar patients without an advance directive.
Other
Peer Reviewed
Age > 65
Dementia
Linking Gap and Impact
2015|
Journal of Clinical Oncology|
Google Scholar|
https://doi.org/10.1200/jco.2015.33.15_suppl.e20557
Outcome type: Favorable
Among patients with advanced disease, obtaining timely advance directives with do-not-resuscitate is likely to result in the lowest daily cost of care for critical patients.
Other
Peer Reviewed
Cancer
Linking Gap and Impact
2017|
N/A|
Google Scholar|
Outcome type: Favorable
The study found that documentation of living wills for lung cancer patients was low, especially among African Americans.
Other
Age > 65
Cancer
Linking Intervention and Impact
2022|
PLoS One|
PubMed|
35925996|
10.1371/journal.pone.0272436
This study examines the availability and effect of end of life decision-making tools on goals of care and advance care planning
Outcome type: Favorable
Advance care planning programs, healthcare provider-led interventions and decision aids increased documentation of end-of-life care plans and do-not-resuscitate orders, and educational tools reduced preferences for life-prolonging care.
Systematic Review
Peer Reviewed
Age > 65
Linking Intervention and Impact
2019|
American Journal of Hospice and Palliative Medicine|
PubMed|
31088134|
10.1177/1049909119848987
This study examines the effect of advance care planning on potentially avoidable hospital admissions at the end of life among hospice-referred patients with cancer
Outcome type: Favorable
The study found that dedicated advance care planning documentation is associated with fewer admissions in the last 30 days of life for patients with advanced cancer referred to hospice.
Other
Peer Reviewed
Age > 65
Cancer
Linking Intervention and Impact
2021|
JAMA Health Forum|
PubMed|
35977213|
10.1001/jamahealthforum.2021.1829
This study examines if billed advance care planning visits are associated with intensive use of health care services at the end of life.
Outcome type: Favorable
Billed advance care planning services during the end of life of patients with serious illness were associated with less intensive use of end of life services.
Prospective Cohort Study
Peer Reviewed
Age > 65
Linking Gap and Impact
2021|
Journal of Pain and Symptom Management|
PubMed|
34062220|
10.1016/j.jpainsymman.2021.05.018
Outcome type: Favorable
End-of-life planning depends on several patient characteristics and circumstances, with socio-economic and racial/ethnic background having the largest effects. Understanding differences that increase end-of-life planning is important to incentivize patients' participation.
Other
Peer Reviewed
Age > 65
Linking Intervention and Impact
2018|
Urology Practice|
PubMed|
37312332|
10.1016/j.urpr.2017.11.001
This is a feasibility pilot study examining completion rate of an advance directive and patient preferences for end-of-life care among men in a urology palliative care clinic.
Outcome type: Favorable
High levels of advance care planning are achievable, and the majority of patients with a terminal illness are averse to aggressive end of life care.
Other
Peer Reviewed
Age > 65
Cancer
Linking Gap and Impact
2021|
Journal of Pain and Symptom Management|
PubMed|
33484795|
10.1016/j.jpainsymman.2021.01.004
Outcome type: Favorable
Older adults who only have power attorneys or only have living wills significantly differed in racial identity, socioeconomic status and health.
Other
Peer Reviewed
Age > 65
Linking Intervention and Impact
2023|
BMC Palliative Care|
PubMed|
37533107|
10.1186/s12904-023-01218-0
Before-after study examining changes in patient-related outcomes and transmural collaboration after implementation of the care pathway which involves timely identification of palliative care needs, advance care planning, multidisciplinary team meetings, warm handover, and follow-up home visits.
Outcome type: Favorable
The intervention did not affect unplanned hospital admissions, however, more patients died at their place of preference after implementation.
Other
Peer Reviewed
Age > 65
Linking Intervention and Impact
2020|
Journal of Palliative Medicine|
PubMed|
32216645|
https://doi.org/10.1089/jpm.2019.05
This study used a questionnaire evaluating a theory-based advance care planning pilot intervention designed to improve decisional quality, readiness, collaboration, and concordance in advance care planning for older adult home health patients and caregivers
Outcome type: Favorable
Results suggest that that collaborative advance care planning decision making may reduce decisional conflict between older adult patients and their caregivers.
Other
Peer Reviewed
Age > 65
Linking Gap and Impact
2023|
Family Practice|
PubMed|
35899787|
10.1093/fampra/cmac062
Outcome type: Favorable
The study found that lack of opportunities was the most common reason for not participating in advance care planning. Patient-centeredness in home medical care facilitates the initiation of advance care planning participation.
Other
Peer Reviewed
Age > 65
Linking Gap and Impact
2018|
Journal of Pain and Symptom Management|
PubMed|
28887268|
10.1016/j.jpainsymman.2017.08.031
Outcome type: Favorable
Advance directive completion was associated with a lower likelihood of receiving life-sustaining treatments during the last month of life in older patients.
Other
Peer Reviewed
Age > 65
Linking Intervention and Impact
2017|
American Journal of Hospice and Palliative Medicine|
PubMed|
27188759|
10.1177/1049909116650237
This study analyzes the effect of advance care planning-specific patient electronic messages on the rate of advance directive completion in older adults.
Outcome type: Favorable
Among patients aged 65 years and older, use of advance directive-specific electronic messaging statistically significantly increased the rate of advance directive completion.
Randomized Controlled Trial
Peer Reviewed
Age > 65
Linking Intervention and Impact
2018|
JAMA Internal Medicine|
PubMed|
30383086|
10.1001/jamainternmed.2018.4657
Randomized clinical trial evaluating the effect of an online, easy-to-read, patient-directed advance care planning program on uptake of advance care planning among older adults.
Outcome type: Favorable
The intervention may mitigate literacy and language barriers to advance care planning, allow patients to begin planning on their own, and could substantially improve the process for diverse English-speaking and Spanish-speaking populations.
Randomized Controlled Trial
Peer Reviewed
Age > 65
Linking Gap and Impact
2022|
BMC Palliative Care|
PubMed|
35501797|
10.1186/s12904-022-00952-1
Outcome type: Favorable
Palliative cancer patients with a prior advance care planning conversation in primary health care spent more days at home and more frequently died at home.
Other
Peer Reviewed
Cancer
Linking Intervention and Impact
2023|
Journal of Medical Internet Research|
PubMed|
38048146|
10.2196/46336
This study evaluates the effectiveness of web-based intervention designed to promote digital health and media literacy by teaching skills that enable users to distinguish trustworthiness of different health apps.
Outcome type: Favorable
The intervention might promote the constructive use of health apps, digital health literacy, and media literacy and improved patient knowledge.
Other
Peer Reviewed
Age > 65
Linking Gap and Impact
2021|
Journal of Palliative Medicine|
PubMed|
32996797|
10.1089/jpm.2020.0153
Outcome type: Favorable
The study found that palliative care consultation is significantly associated with better end-of-life outcomes among patients with end-stage renal disease with more completion of ACP and hospice referral in patients.
Other
Peer Reviewed
Age > 65
End-Stage Renal Disease
Linking Intervention and Impact
2021|
Healthcare|
PubMed|
35052226|
10.3390/healthcare10010062
This study examines the association between advance care planning inventory and its effect on quality of dying among individuals in group homes for persons with dementia.
Outcome type: Favorable
The implementation of advance care planning improves the quality of dying.
Other
Peer Reviewed
Age > 65
Linking Intervention and Impact
2023|
BMC Health Services Research|
PubMed|
37264350|
10.1186/s12913-023-09593-3
Study examining the effect of an app promoting advance care planning on patient motivation to write advance directives.
Outcome type: Favorable
Overall, the intervention had a positive effect on the mean reported advance care planning engagement for all variables.
Randomized Controlled Trial
Peer Reviewed
Age > 65
Linking Intervention and Impact
2022|
JAMA Psychiatry|
PubMed|
35662314|
10.1001/jamapsychiatry.2022.1627
Study examining the effect of psychiatric advance directives facilitated by peer workers on compulsory hospital admissions among patients with mental illness. The intervention group completed a psychiatric advance directive form and met with a peer worker who was trained to assist in completing and sharing the form with relatives and psychiatrists.
Outcome type: Favorable
Peer worker-facilitated advance directives are effective in decreasing compulsory hospital admissions and increasing some mental health outcomes.
Randomized Controlled Trial
Peer Reviewed
Linking Intervention and Impact
2015|
Critical Care Medicine|
PubMed|
25574794|
10.1097/CCM.0000000000000852
Systematic review examining effect of palliative care interventions and advance care planning on ICU utilization.
Outcome type: Favorable
Patients who received advance care planning or palliative care interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay.
Systematic Review
Peer Reviewed
Linking Intervention and Impact
2022|
American Journal of Hospice and Palliative Medicine|
PubMed|
35040696|
10.1177/10499091211072850
Observational study examining the effect of an educational program for emergency physicians on advance care planning conversations among patients in the emergency department during the COVID-19 pandemic. Patients received an advance care planning training toolkit and emergency departments physicians received an advance care planning educational session.
Outcome type: Favorable
A quick and simple physician-facing educational intervention, though lacking in statistical significance, increased emergency department-based advance care planning activities for patients with COVID-19.
Other
Peer Reviewed
Age > 65
Linking Intervention and Impact
2016|
Maturitas|
PubMed|
27451328|
10.1016/j.maturitas.2016.06.016
This study reviews the use of advance care planning with older adults across clinical settings.
Outcome type: Neutral
Advance care planning interventions are well received by older adults and generally have positive effects on outcomes.
Systematic Review
Peer Reviewed
Age > 65
Linking Gap and Impact
2022|
Scandinavian Journal of Primary Health Care|
PubMed|
35170393|
10.1080/02813432.2022.2036429
This study uses a retrospective chart review on studies on advance care planning in nursing home settings.
Outcome type: Favorable
Patients with care plans more frequently received prescriptions of palliative drugs and family members were better informed about the patient’s condition and impending death compared to those without care plans.
Other
Peer Reviewed
Age > 65
Linking Intervention and Impact
2016|
International Journal of Nursing Studies|
PubMed|
35667145|
10.1016/j.ijnurstu.2022.104276
This study aims to determine the effect of advance care planning interventions on end of life outcomes in nursing home patients.
Outcome type: Favorable
Advance care planning intervention increased the number of documented end-of-life care wishes but demonstrated no effect on satisfaction with end-of-life care from family caregivers' perspectives.
Systematic Review
Peer Reviewed
Age > 65
Linking Intervention and Impact
2022|
Palliative & Supportive Care|
PubMed|
34446129|
10.1017/S1478951521001152
This study performs aa systematic review examining RCTs of advance care planning interventions adapted for limited health literacy.
Outcome type: Favorable
Health literacy interventions increased participant knowledge, preference for comfort care, engagement, and care documentation.
Other
Peer Reviewed
Age > 65
Linking Gap and Impact
2021|
BMJ Supportive & Palliative Care|
PubMed|
33753359|
10.1136/bmjspcare-2020-002851
Outcome type: Favorable
Advance directives are an effective tool to adjust the occurrence of some procedures at the end of life and improve treatment plans.
Other
Peer Reviewed
Age > 65
Linking Gap and Impact
2016|
Frontiers in Oncology|
PubMed|
27822458|
10.3389/fonc.2016.00223
This piece performs a systematic review examining studies of advance care planning in patients with primary malignant brain tumors.
Outcome type: Favorable
Positive effects of advance care planning included lower hospital readmission rates, and intensive care unit utilization.
Systematic Review
Peer Reviewed
Linking Intervention and Impact
2023|
Annals of Palliative Medicine|
PubMed|
37574575|
10.21037/apm-22-1261
This is a narrative review examining advance care planning, serious illness communication, and conversations to facilitate coping for patients with gastrointestinal (GI) malignancies.
Outcome type: Favorable
Serious illness communication for future treatment has the potential to benefit patients with advanced GI malignancies in a variety of ways.
Other
Peer Reviewed
Linking Intervention and Impact
2021|
American Journal of Hospice and Palliative Medicine|
PubMed|
32648476|
10.1177/1049909120940210
Patients with gastrointestinal and lung malignancies were randomized to the web or paper advance directives.
Outcome type: Favorable
Satisfaction with advance care planning and AD acceptability were high in both groups and not significantly different. Web-based advance directives hold promise for promoting documentation and sharing of preferences.
Randomized Controlled Trial
Peer Reviewed
Linking Intervention and Impact
2019|
Journal of American Board of Family Medicine|
PubMed|
31704762|
10.3122/jabfm.2019.06.190016
The study was a geriatric clinic pilot of a multi-modal population-based outreach strategy for portal-based advance care planning tools.
Outcome type: Favorable
Brief motivational messages about advance care planning via a patient portal is feasible and may increase advance care planning outcomes for older adults in primary care.
Other
Peer Reviewed
Linking Gap and Impact
2023|
Palliative Care & Social Practice|
PubMed|
38033875|
10.1177/26323524231212513
Outcome type: Favorable
Preparedness for the future with a living will varies according to services and on individual level. Advance care planning may reduce inequalities in end-of-life care.
Other
Peer Reviewed
Age > 65
Linking Intervention and Impact
2022|
BMC Palliative Care|
PubMed|
36224540|
10.1186/s12904-022-01068-2
The intervention group received two patient decision aids that met the international criteria developed by the researchers for patients before surgery. Study participants were patients scheduled to be admitted to the intensive care unit after surgery at one acute care hospital in Japan and their families.
Outcome type: Favorable
Patients reported that using the intervention provided an opportunity to share their thoughts with their families and inspired them to start mapping their life plans, and patients wanted to share and discuss their decision-making process with medical professionals after the surgery.
Other
Peer Reviewed
Linking Intervention and Impact
2019|
Patient Centered Outcomes Research Institute (PCORI)|
PubMed|
Randomized controlled trial in which intervention group viewed an advance care planning video. Patients randomized to the control arm viewed an informational video about the hospital surgical program.
Outcome type: Neutral
Patients found the advance care planning video helpful, but it did not significantly change the nature of the patient–surgeon communication or the content of ACP in the preoperative patient–surgeon conversation.
Randomized Controlled Trial
Peer Reviewed
Cancer
Linking Intervention and Impact
The acceptability and effect of a communication-based advance care planning program for older adults
2021|
Journal of Hospice and Palliative Nursing|
PubMed|
34185729|
10.1097/NJH.0000000000000762
The intervention is a patient-centered advance care planning program with surrogates and a structured and guided discussion by home health care nurses as the trained interventionists.
Outcome type: Favorable
The outcomes of this study suggest that the intervention may have a potential improvement on end-of-life care decision making for older adults in South Korea.
Randomized Controlled Trial
Peer Reviewed
Age > 65
Linking Gap and Impact
2023|
BMC Palliative Care|
PubMed|
37062841|
10.1186/s12904-023-01168-7
Outcome type: Favorable
There are differences in the presence of legal advance care planning across ethnic groups despite similar presence of informal end of life conversations.
Systematic Review
Peer Reviewed
Linking Intervention and Impact
2019|
Journal of the American Geriatrics Society|
PubMed|
30675898|
10.1111/jgs.15769
This study describes end of life care preferences and acute care and hospice use for individuals in comprehensive dementia care management program.
Outcome type: Favorable
The study found that patients in a comprehensive dementia care comanagement program had high engagement in advance care planning, high rates of hospice use, and low acute care utilization near the end of life.
Other
Peer Reviewed
Dementia
Linking Intervention and Impact
2022|
Journal of the American Geriatrics Society|
PubMed|
34758115|
10.1111/jgs.17540
This study aims to determine whether PREPARE program increases clinician advance care planning communication.
Outcome type: Favorable
The PREPARE program was associated with greater clinician supportive ACP communication with older adults compared with an AD alone. The effect was strongest among Spanish speakers and was mediated by active patient participation. The intervention helps patients be more engaged communicators, which in turn encourages clinicians to be more supportive of patients. Enhanced patient-clinician communication may reduce disparities in advance care planning.
Other
Peer Reviewed
Age > 65
Linking Intervention and Impact
2022|
Clinical Journal of the American Society of Nephrology|
PubMed|
36104084|
10.2215/CJN.00090122
Study examining the effect of a learning collaborative between hemodialysis centers improvement of palliative care among hemodialysis patients.The learning collaborative involved learning sessions, communication skills training, and implementation support.
Outcome type: Favorable
A learning collaborative for hemodialysis centers spanning the coronavirus pandemic was associated with adoption of serious illness screening and goals of care discussions as well as improved documentation of advance care planning for seriously ill patients.
Other
Peer Reviewed
Age > 65
Linking Intervention and Impact
2022|
Annals of Palliative Medicine|
PubMed|
34775775|
10.21037/apm-21-2161
A non-randomized controlled trial evaluating the effect of advance care plannign discussions with providers on knowledge, advance care planning readiness, self effiacy, and quality of life. among chronically ill people aged 65 years and older.
Outcome type: Favorable
The study found that older adults with chronic diseases can have better communication with their families and health care providers and a higher quality of life if they engage in advance care planning discussions with trained nurses at an early stage.
Other
Peer Reviewed
Age > 65
Linking Intervention and Impact
2020|
Journal of Pain Symptom Management|
PubMed|
31866488|
10.1016/j.jpainsymman.2019.12.353
The intervention was a video that provided information about advance care planning and end-of-life care options such as cardiopulmonary resuscitation and palliative care. An attention-control arm was given a booklet about advance directives.
Outcome type: Favorable
A well-constructed video decision support intervention can increased patients' intention to document advance care planning in the general population.
Randomized Controlled Trial
Peer Reviewed
Linking Intervention and Impact
2018|
Journal of the American Geriatrics Society|
PubMed|
30289968|
10.1111/jgs.15554
Study examining the effect of a surgical optimization program on advance care planning uptake among older adults. In the surgical optimization program, participants received an advance care planning discussion with a provider, and trained medical and nurse practitioner students were used as health coaches who contacted participants regularly to address and document advance care planning.
Outcome type: Favorable
Preoperative optimization programs provide a unique opportunity to engage older adults in advance care planning.
Other
Peer Reviewed
Age > 65