Integrated Multidisciplinary Patient and Family Advance Care Planning Trial

This study is a randomized, pragmatic, comparative effectiveness trial for determining better
ways to engage multimorbid patients and their family members in Advance Care Planning through
a Nurse Navigator led pathway versus usual care. Investigators propose to utilize Zelen's
design (a more recent label/generalization for this type of design is the cohort multiple
randomized controlled trial (cmRCT), a pragmatic clinical trial design whereby all
participants are randomized prior to informed consent, and then only patients randomized to
the interventional arm are approached for consent and subsequently enrolled in the
intervention group.

Inclusion Criteria:

- Aged 65 or older patient within the Wake Forest/Cornerstone ACO

- Have seen their primary care provider within the Wake Forest/Cornerstone network in
the past 12 months

- English speaking

- No documented Advance Directive in the EHR

- Impairments in either physical function, cognition, and/or frailty

Exclusion Criteria:

- No available proxy (e.g. in setting of cognitive impairment)

- Severe/advanced dementia

- Moderate to severe hearing loss

- Non-English speaking

- No phone number available for patient