TOPLINE:

Automated tools for advance care planning (ACP) helped increase the number of advance directives and Physician Orders for Life-Sustaining Treatment (POLST) forms on file. The biggest gains came from the version that added health navigator support — nearly 1 in 5 participants had documented advance care forms after 2 years. 

METHODOLOGY:

• Researchers conducted a cluster randomized trial across 50 primary care clinics at three University of California health systems involving 5810 adult patients with serious illnesses like advanced heart failure or end-stage renal disease (mean age, 71 years; 48% women; 50% racial or ethnic minority patients) without prior ACP documentation.
• Clinics were randomly assigned to implement one of three interventions:
  • Automated interventions such as messages through the electronic health record (EHR) portal and mailed materials to raise awareness and promote the completion of an advance directive (17 clinics)
  • Automated interventions and a link to PrepareForYourCare.org along with a related pamphlet (18 clinics)
  • Automated interventions plus link and pamphlet, along with health navigator outreach, under which the navigators provided reminders and education about ACP, supporting patients in reviewing their advance directives and discussing preferences with clinicians (15 clinics)
• Interventions were sent to patients 7-21 days prior to a primary care appointment or after 6 months if no suitable appointment was available, with a follow-up duration of 24 months.
• The primary outcome was the presence of an advance directive or POLST form in the EHR at 12 and 24 months, with secondary outcomes including documented discussions with the clinician and healthcare utilization.

TAKEAWAY:

• Overall, 60% of patients receiving automated interventions only, 65% receiving automated interventions and the link, and 67% receiving health navigator outreach accessed the EHR message.
• Among those receiving navigator outreach, 82% received assistance, and at 24 months, 19.8% had an advance directive or POLST form in the EHR.
• Patients who received health navigator outreach had a higher likelihood of having a documented ACP form at 24 months than those who received automated interventions only (adjusted difference, 4.6%; P < .001) and those who received automated interventions and the link (adjusted difference, 5.5%; P < .001).
• Patients in the health navigator outreach group also had a higher likelihood of having documented ACP discussions than those in the automated intervention only and automated intervention plus link groups (adjusted difference, 4.7%; P = .002 and adjusted difference, 4.2%; P = .004, respectively).
• No significant differences were observed in healthcare utilization, including emergency department visits, hospitalizations, and ICU admissions.

IN PRACTICE:

“The findings highlight that having an active component to an ACP intervention is probably necessary to achieve more meaningful effects,” experts wrote in an accompanying editorial.

SOURCE:

The study was led by Anne M. Walling, MD, PhD, of the Division of General Internal Medicine and Health Services Research at the University of California, Los Angeles. It was published online on November 25, 2025, in the Annals of Internal Medicine.

LIMITATIONS:

The absence of a control group and staggered intervention initiation may have affected the findings. Documentation was limited to EHR records, excluding external notes, and the cost-effectiveness of the intervention remained unassessed.

DISCLOSURES:

The study was supported by a grant from the Patient-Centered Outcomes Research Institute. Several authors disclosed employment, grants, royalties, consulting fees, or contracts from various sources including the Patient-Centered Outcomes Research Institute, among others. 

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.