Utilizing the Care Assessment Need (CAN) score to identify vulnerable male veterans who would benefit from advance directives in a resident primary care clinic at the Northport Veteran Affairs Medical Center

From the 2023 HVPA National Conference

Kalyani Dhar MD (Stony Brook University Hospital), Lisa Fisher M (Northport VA Medical Center)

Advance care planning helps providers understand future healthcare decisions if an individual is no longer able to make those decisions on his/her own. Per the American Geriatrics Society, it is believed that advance care planning is a critical tool for helping individuals document their wishes and care values so that the care they receive matches with their wishes. This becomes more important near the end of life [1]. However, as seen in a study by UPenn in 2017, “Among the 795,909 Americans from the 150 included studies, we found that 36.7 percent had completed some advance directive. Only 29.3 percent had completed a living will that contains actual care wishes, and 33.4 percent had designated a health care power of attorney” [2].

The CAN score reflects the estimated probability of hospital admission or death within 90 days or 1 year. The score ranges from 0 (low risk) to 99 (highest risk) and is generated using statistical prediction models that utilize the patient’s demographics, clinical information in the EMR, and socioeconomic status. Although the CAN score represents probabilities and may not be predictive for every veteran who has a high score, we felt that it was important to outreach to these vulnerable veterans who would benefit most from completing NYS MOLST and HCP forms.

From 9/2021 – 12/2021, male veterans with a CAN score 90-99 had their chart reviewed and were called to discuss the importance of advance directives.

A total of 497 veterans had a CAN score 90-99 of whom 75 already had advance directives completed at the VA (15.09%) and 37 already had them completed outside of the VA (7.44%), showing a 22.54% rate of completed advance directives. For the remaining 385 veterans, 42 completed goals of care/life sustaining treatment plan (10.91%) after our outreach, 78 agreed to an appointment specifically to complete it (20.26%) and 63 wanted to complete it at their next PCP appointment (16.36%). Unfortunately, 16 veterans no showed/cancelled their appointment for advance directives (4.16%), 113 couldn’t be reached despite multiple attempts (29.35%), 32 refused (8.31%), and 15 had changed providers or moved (3.9%). Understanding that this is a difficult topic of conversation, 26 had opted to think about it more or discuss it with their family first (6.75%).

Although many these veterans couldn’t be reached or refused, this outreach did have a positive impact with 183 veterans who completed or would soon complete it at a PCP appointment with an additional 26 who were now thinking about it.

Clinical Implications:
Given what was seen during the COVID-19 pandemic and its uncertainty for even healthy individuals, it is important to continue this outreach to and education of our vulnerable veterans to document their wishes when they can provide them themselves.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog