Background Priority Health Case Managers (CMs) work telephonically with frail patients that have multiple co-morbidities. CMs have lacked facilitation skills for Advance Care Planning (ACP) discussions in this vulnerable population. Following a 6-month pilot of telephonic ACP (TACP) in the Medicare population, TACP was implemented for the entire Medicare CM staff.

Aim To engage identified patients in First Steps© and Last Steps© TACP.

Methods CMs were trained and certified by Respecting Choices© to facilitate ACP discussions telephonically with both First Steps© and Last Steps© protocols. CMs identified appropriate patients using hospitalisation and emergency room utilisation data, severity of illness and diagnostic criteria. The primary goal was to complete both the ACP discussion and document for each protocol on identified patients. CMs also attempted to schedule facilitated conversations with the health care advocate present.

Results In one calendar year, 155 patients were identified for TACP using established criteria. 59% indicated they had an existing document identifying preferences for medical care. 35% declined TACP. Last Steps© discussions occurred in 15% of the patients. TACP resulted in eight new or updated documents.

Discussion Following TACP implementation to the Medicare CM team and evaluation of the results, processes and methods were instituted to increase engagement and completion of discussions and documents. These included enhancements to the electronic assessment and ongoing support of the CM team to increase engagement of patient and advocate.

Conclusion Dissemination of the project to the entire Medicare CM team demonstrates opportunities and lessons learned for facilitated TACP discussions.