Consumer Engagement to Increase Advance Care Planning
Consumer Engagement to Increase Advance Care Planning
The specific aims of the project are: 1) to test the effectiveness of consumer-directed
 financial incentives paired with provider-directed financial incentives, compared to
 provider-directed financial incentives alone, for increasing advance care planning (ACP)
 among Medicaid beneficiaries; and 2) to assess perceptions regarding the appropriateness of
 consumer-directed financial incentives for ACP among study participants. The investigators
 hypothesize that consumer-directed financial incentives will result in a 15-percentage point
 absolute increase in the proportion of subjects completing ACP. The investigators do not
 advance hypotheses about the qualitative component.
This is a parallel cluster randomized controlled single-blind trial of consumer-directed
 financial incentives paired with provider-directed financial incentives (intervention),
 compared to provider-directed financial incentives alone (control) on the completion of ACP
 among Partnership HealthPlan of California (PHC) Medi-Cal patients. PHC is a county-organized
 health system contracted by the State of California to provide a health care delivery system
 for 360,000 Medi-Cal beneficiaries in Northern California. PHC has 400 contracted Primary
 Care Provider (PCP) entities, representing over 2000 individual physicians, working in solo
 practice, small groups, community health centers, large groups, and integrated health
 systems. The rationale for using PHC is their commitment to experimenting with strategies to
 improve ACP, including their current quality improvement program incentive payment to PCPs to
 discuss and document ACP with patients 65+ and <65 with a serious chronic illness.

 The investigators will randomize 40 PCPs to one of two different patient education packets
 for their patients. Each PCP is eligible for financial incentives for documenting ACP (usual
 care), regardless of the randomization group.

 Each PCP will be responsible for identifying and enrolling 10 eligible subjects during
 routine clinic visits, for a target enrollment of 400 patient subjects.

 The investigators will stratify randomization based on salience of the financial incentive
 (e.g., accrues directly to non-salaried provider, such as in a private practice, or accrues
 to the organization of a salaried provider, such as in a Federally Qualified Health Center or
 multispecialty group).

 All enrolled patients will receive access to the patient education tool, Prepare for Your
 Care (www.prepareforyourcare.org), developed by Dr. Sudore for low-literacy Medi-Cal
 populations, in their education packets. The intervention group patients will additionally be
 offered a consumer (patient) financial incentive. the primary outcome of the study is having
 a conversation with the PCP about ACP. Secondary outcomes include: 1) website use metrics and
 2) attitudes about providing financial incentives for ACP (among a purposively sampled subset
 of participants).
PCP Subject Inclusion Criteria:

 -  Partnership HealthPlan of California Medicaid and/or Medicare provider

 PCP Subject Exclusion Criteria:

 -  Prohibition by clinic director

 Patient Subject Inclusion Criteria:

 -  Partnership HealthPlan of California Medicaid and/or Medicare enrollee;

 -  Age 65+ or < 65 with a life-limiting illness (including advanced cardiac disease
 [end-stage congestive heart failure, severe coronary artery disease, cardiomyopathy
 (LVEF <25%)], advanced chronic obstructive pulmonary disease, amputation due to
 vascular disease, cancer [metastatic/recurrent], dementia, diabetes mellitus with
 creatinine clearance under 50, or an amputation, end stage renal disease, generalized
 debility and decreased functioning, long term resident of skilled nursing facility,
 stroke [w/at least 50% decreased function]);

 -  Internet access (computer, tablet, phone)

 Patient Subject Exclusion Criteria:

 -  Completion of a Partnership HelathPlan of California advance care planning attestation
 form within the last 12 months;

 -  Inability to read English