It is not known how remuneration for advance care planning and end of life issues (ACPEL) discussions influences physician practice. In Calgary, AB family physicians get remunerated for completing a comprehensive annual care plan proforma (CACP) with patients who have complex care needs. The CACP prompts the physician to ACPEL discussions, with a tickbox answer of yes, no or not applicable.. The local “goals of care designation” (GCD) policy communicates treatment intent, based on medically appropriate care and the patient's own goals. Although not part of the CACP, if discussing ACPEL, determining a GCD is often appropriate.
From a practice of 4000, 59 patients were identified by searching all CACP billing codes submitted from April 1st, 2011 through September 30th. A retrospective notes analysis revealed the percentage of charts with the ACPEL question completed was 49%. Of those that were completed 17% had discussed ACPEL, 17% had not and 66% selected not applicable. Only 1 out of 59 patients had a GCD and that was not determined during their CACP.
Despite being part of a defined, remunerated plan, ACPEL and GCD discussions are not occurring. This baseline data will inform interventions in an audit feedback cycle, including practice-based physician education and mentoring on facilitating ACP conversations and improved clinic processes to ensure patient access to ACP material and to attach GCD documentation to the CACP. In addition it suggests the need for more effective links between remuneration to ACPEL discussions.
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