ORIGINAL STUDIES

Improving Rates of Advance Directive
Discussions Among Managed Care
Nursing Home Enrollees
Vincent W. DeLaGarza, MD, Ross E. Andersen, PhD, John Mach, MD, and Richard G. Bennett, MD
Background: Discussions about advance directives
should be offered to all nursing home residents. Managed Medicare programs for nursing home residents
allow for the development of performance improvement initiatives to ensure that these discussions occur
and are documented.
Purpose: To assess the effectiveness of an intervention
to increase discussion and documentation of advance
directives for enrollees in a managed Medicare program for nursing home residents, and to evaluate
whether this intervention affected preferences for
cardiopulmonary resuscitation (CPR) and hospitalization among enrollees.
Subjects: Participants were 4,248 enrollees in a managed Medicare program in 1996, and 6,598 enrollees
in 1997, in Georgia, Maryland, Massachusetts, Minnesota, Arizona, and Florida.
Design: Descriptive study of a quality improvement
initiative.
Methods: A chart review was conducted in the fall of
1996 to determine the prevalence of documented advance directive discussions among all enrollees, and
the preferences regarding CPR and hospitalization.
Because the discussion rates varied across sites, and
were lower than expected, each site developed strategies to improve advance directive discussion and documentation. One year later, a similar survey was con-

There are approximately 1.5 million nursing home residents residing in 16,700 nursing facilities in the United
States.1 The majority have chronic illnesses of varying severJohns Hopkins University School of Medicine, Division of Geriatric Medicine
and Gerontology, Johns Hopkins Geriatrics Center, Baltimore, MD (V.W.D.,
R.E.A., R.G.B.) and UnitedHealth Group, EverCare, Minnetonka, MN (J.M.).
Address correspondence to: Richard G. Bennett, MD, Johns Hopkins Geriatrics
Center, 5505 Hopkins Bayview Circle, Baltimore, MD 21224, email:
rbennett@jhmi.edu

Copyright ©2001 American Medical Directors Association
ORIGINAL STUDIES

ducted to determine the efﬁcacy of the interventions,
as well as to assess the impact, if any, on rates of desire
for CPR and hospitalization.
Results: Documented discussions of advance directives
increased across the six sites from 73% to 85% (P Ͻ
0.001). The overall percentage of patients desiring CPR
did not change following the intervention (18%).
However, there were geographical differences in the
desire for CPR among enrollees, with those in Minnesota (8%), Arizona (11%), and Florida (12%) desiring it
the least, and those in Massachusetts (20%), Georgia
(29%), and Maryland (29%) desiring it the most. The
overall percentage of desire for hospitalization decreased from 65% to 62% (P Ͻ 0.001). Enrollees in
Georgia were most likely to want hospitalization
(87%), and enrollees in Minnesota were the least likely
to want hospitalization (57%).
Conclusions: In a managed care program, documentation of advance directive discussions can be increased
with focused efforts. Overall, most enrollees did not
desire CPR, but a majority desired hospitalization. Despite the similarity of interventions and program philosophy across sites, signiﬁcant geographic variations
in desire for CPR and hospitalization remained. (J Am
Med Dir Assoc 2001; 2: 105–109)
Keywords: Advance directives; nursing home; managed care

ity requiring regular medical assessments, as well as frequent
acute illnesses needing treatment. Most of these individuals
receive their medical care in a traditional Medicare fee-forservice program, although new ways of delivering health care
to this population are being explored.
EverCare is a managed care organization that currently
provides Medicare part A and B services to more than
10,000 permanent nursing facility residents. EverCare
nurse practitioners (NPs) and physician assistants (PAs)
collaborate with physicians to enhance the primary care
DeLaGarza et al. 105

provided to long-stay nursing facility residents. The concept was initially developed in 1987 by a group of NPs in
Minnesota in order to improve the quality of health care
delivered to this population, and the Health Care Financing Administration approved a demonstration project of
the model in up to nine different cities in the 1990s. The
implementation of this project has recently been reported.2
Managed care for nursing home patients is a relatively new
phenomenon, and little is known about how it compares to
traditional care in nursing facilities. There is some evidence
that it may decrease the hospitalization rate for nursing facility patients without increasing mortality.3 Indicators of quality have not been compared between the managed care and
fee-for-service systems, but as part of its quality assurance
program, EverCare collects data for several clinical indicators
including whether or not discussions of advance directives
have been documented.
Addressing patient and family desires for treatment is important for maintaining the dignity and comfort of any patient. Historically, efforts to identify patient desires for treatment have been less than ideal, and the Patient Self
Determination Act (PASDA) was passed by Congress in
1991 to rectify this situation. This act mandates that future
treatment be addressed for patients in nursing homes and
hospitals. However, despite the passage of PASDA, many
residents of nursing homes still do not have their wishes for
future treatment documented.4,5 The purpose of this investigation was to describe a quality improvement intervention
designed to promote advance directive discussion and documentation among enrollees in a managed Medicare program
for long-stay nursing home patients, and to determine if the
intervention affected the desire for CPR and hospitalization
among these enrollees.
METHODS
Study Population
Residents from approximately 100 nursing facilities in
Georgia, Maryland, Massachusetts, Minnesota, Arizona,
and Florida who enrolled in a managed Medicare program.
In the fall of 1996, 4,248 enrollees were surveyed. One year
later, following continued planned growth in the program,
6,598 enrollees were surveyed.
Description of the Managed Medicare Program
Long-stay nursing home residents and/or their responsible
family members or guardians were solicited by specially
trained managed care employees to enroll in the managed
Medicare program. Each nursing facility with enrollees was
certiﬁed by Medicare and Medicaid. In this managed care
model, nurse practitioners or physician assistants employed by
the managed care company worked with facility physicians to
provide care for enrollees. Both NPs and PAs were licensed by
the state in which they practiced, and credentialed by the
managed care program. Most facility physicians were trained
in internal medicine or family medicine, and all were credentialed by the managed care program. NPs or PAs were employed by the managed care program, and underwent stan106 DeLaGarza et al.

dardized instruction at hiring to ensure their understanding of
the model of care. In addition, regular in-service training
occurred for NPs and PAs on a variety of topics including the
importance of obtaining advance directives. Each NP or PA
typically cared for 80 –120 enrollees. NPs or PAs provided
daily visits, Monday through Friday, for chronic care and
management of acute illnesses. Physicians, PAs, and NPs were
encouraged and expected to evaluate complicated patients
together on regular occasions and to function as a team.
Study Design
The EverCare model stresses the importance of planning
for care at the end of life and when acute illness occurs, and
therefore, discussion and documentation of advance directives are a foundation of the program. All NPs and PAs
received instruction in this regard, and were familiar with
the methods of establishing advance directives for enrollees
by direct discussion with those residents who had the
capacity to make their own decisions, or through the involvement of family members or guardians for those who
lacked capacity. No formal programs were in place in any
site to determine whether or not an enrollee had capacity
to make advance directives, but since more than 70% of
national enrollees were diagnosed with dementia, and all
were functionally dependent, family members or guardians
were involved in the vast majority of discussions. Language
barriers, if any, were addressed through the use of appropriately ﬂuent practitioners or translators.
This was a descriptive study using data collected before and
after a formal effort was made to increase documentation of
advance directive discussions. An initial survey in 1996 revealed that documentation of advance directive discussions
was only recorded for 57– 83% enrollees (overall average
73%) across the six sites. Each site developed an intervention
program to increase the percentage of enrollees with whom a
discussion of advance directives had occurred, and to ensure
proper documentation. The efforts varied by site, but included
advance directive seminars for NPs and PAs; letters sent to
providers including practice guidelines and recommendations
to discuss and document advance directives; and letters to
providers, NPs, and PAs with results of record reviews for
individuals and peers regarding compliance with documentation standards. No data were available in this study with
respect to the identity of advance directive discussants.
In both years, data were collected by NPs and PAs who
were employees of the health plan, and who were given
formatted instruments to tabulate documentation of advance directive discussions with either the enrollee, a family member, or surrogate. Information on the desire for
CPR and hospitalization was also collected. Senior health
plan personnel with medical training reviewed the data at
each site and nationally.
CPR meant instituting basic life support and the calling of
911 units in the involved locales and/or the use of automatic
external deﬁbrillators or stand-alone standard deﬁbrillators
already present within some nursing homes. The potential
beneﬁt, risks, and likely outcome of hospitalization were also
discussed with patients. For those who did not wish to be
JAMDA – May 2001

Table 1. Number of enrollees by site
Site

1996

1997

Georgia
Maryland
Massachusetts
Minnesota
Arizona
Florida
Total

461
481
596
1696
809
200
4248

1001
1327
1089
1580
988
613
6598

hospitalized, the managed care program could arrange for
treatment including intravenous hydration or medication
in the nursing home. Sophisticated monitoring devices
(apart from pulse oximetry in some facilities) were not
present within most nursing facilities, and patients or their
surrogates were informed that treatment and monitoring
would not be at the same intensity as within a hospital.
(Comfort care was also an option for some of those who did
not want to be hospitalized, and included symptomatic
treatment of pain and dyspnea without an intent to cure.
No data were reviewed pertaining to the percentage who
opted for comfort care.)
Statistical Analysis
Statistical analysis was carried out using SPSS Version 9
software. Differences in variables between 1996 and 1997
were compared using chi-square analysis.
RESULTS
The number of enrollees in each of the six sites is shown
in Table 1. The mean age for all enrollees was 85 years and
did not vary across sites. The overall percentages (ranges
across sites) of enrollees by racial category were 87% (74 –
92%) white, 11% (1.5–25%) African-American, 1.4%
(0.3– 6.1%) hispanic, and 0.3% (0.1– 0.4%) other racial
group. The percentage of African-American enrollees was
highest in Georgia (25%) and Maryland (23%), and Arizona had a signiﬁcantly higher (P Ͻ 0.01) proportion of
Hispanic enrollees (6.1%) compared to the other sites.

Fig. 1. Percentage of enrollees by site with documentation of
advance directive discussions before (1996) and after (1997) an
intervention to increase advance directive discussion and
documentation.

Changes in CPR Preferences
Figure 2 illustrates the regional and overall changes in
the prevalence of enrollees desire for CPR. The overall rate
remained unchanged at 18% in both years, but regional
differences remained in the proportions of enrollees desiring CPR following the intervention. Signiﬁcant decreases
in desire for CPR occurred in Georgia and Massachusetts
(both P Ͻ 0.001), where baseline desire for CPR were
among the highest initially. In Maryland, Minnesota, Arizona, and Florida, the proportion of enrollees who desired
CPR did not change (all P ϭ 0.570).
Changes in the Desire for Hospitalization
Figure 3 illustrates the regional and overall changes in the
prevalence of enrollees who reported desiring hospitalization.
The overall desire for hospitalization decreased after the intervention (65% versus 62%, P Ͻ 0.001). Regional differences in the proportions of enrollees desiring hospitalization

Changes in Rates of Documentation of Advance
Directive Discussions
Figure 1 illustrates the regional and overall changes in the
prevalence of a member having a documented discussion of
advance directives. Advance directive documentation occurred in 73% of enrollees in 1996. This proportion increased
signiﬁcantly to 85% (P Ͻ 0.001) in 1997 after each site
established programs to improve the rates of discussion and
documentation of advance directives.
Regional differences were observed in the likelihood that
site-speciﬁc interventions increased documentation in the
proportion of enrollees for whom advance directives were
addressed. The proportion increased in Georgia, Maryland,
Massachusetts, and Arizona (P Ͻ 0.001), but was unchanged
in Minnesota and Florida (P ϭ 0.367). No data were available
to comment upon or compare the efﬁcacy of the intervention
programs carried out in the six sites.
ORIGINAL STUDIES

Fig. 2. Percentage of enrollees by site with desire for CPR
before (1996) and after (1997) an intervention to increase
advance directive discussion and documentation.
DeLaGarza et al. 107

Fig. 3. Percentage of enrollees by site with desire for
hospitalization before (1996) and after (1997) an intervention to
increase advance directive discussion and documentation.

were observed, with decreases occurring in Maryland, Massachusetts, and Arizona (all P Ͻ 0.001)—all sites where the
baseline desire for hospitalization was greatest; no change in
Minnesota (57% versus 59%, P ϭ 0.247); and an increase in
Florida (45% versus 58%, P Ͻ 0.001).
DISCUSSION
The principal ﬁnding of this study was that discussion
and documentation of advance directives can be increased
with education of health care providers. Even though the
initial overall rate of discussion and documentation among
the managed care program enrollees (73%) was higher than
previously reported averages for nursing home residents,4
further improvement occurred after the targeted interventions. Although geographical differences in the documentation of advance directive discussions were present among
enrollees at baseline, after the intervention these differences had virtually been eliminated. The high initial rate
in Minnesota is reﬂective of the maturity of the site where
the program began, and the high initial rate in Florida is
explained by the initiation of the program in that state by
a small group of physicians committed to the model.
Despite the fact that similar interventions occurred at
each site, interesting geographical differences remained
following the intervention among the sites with respect to
the percentage of enrollees who desired CPR and hospitalization. The higher rates of desire for CPR among enrollees
in Georgia (29%) and Maryland (29%) may be reﬂective of
the relatively higher percentage of African-Americans in
these two sites as compared to sites with the lowest rates,
Minnesota (8%) and Arizona (11%). Racial and geographical differences in desire for life-prolonging treatment have
been reported previously,5-7 and although this effect was
not rigorously explored in this project, our data are consistent with these earlier reports. Similarly, geographical
differences remained with respect to desire for hospitalization ranging from 43% to 77%. There is no obvious expla108 DeLaGarza et al.

nation for these geographical differences, but the fact that
more than a third of enrollees overall do not want to be
hospitalized is a ﬁnding that shows the importance of
offering this option to nursing home residents and their
surrogate decision-makers as part of advance directive
discussions.
The ﬁndings of this study may not be generalizable to all
nursing home residents. Enrollees in this program were longstay residents, i.e., nursing home residents admitted for a short
post-acute hospital stay were not eligible for enrollment in the
managed Medicare program. Since many long-term care facilities now provide services for a signiﬁcant number of shortstay patients who may have quite different desires with regards
to advance directives, comparison of our ﬁndings with other
future reports must be done with caution. In addition, those
who enroll in a managed care program may have other characteristics that make them different from typical nursing
home residents, or from those who decline to enroll. No data
were available to allow for such comparisons to be made in
this project.
Finally, no data pertinent to the quality of the advance
directive discussions that were documented were available
for analysis. Similarly, questions could not be addressed
regarding whether or not any differences existed between
enrollee and family member/guardian preferences for cardiopulmonary resuscitation and hospitalization, as has been
reported in other studies of advance directives.8-10 Therefore, the results of this study should be interpreted in the
light of its limitation as a straightforward quality assurance
project that shows that documentation of discussions of
advance directives can be increased, and not interpreted as
making any commentary as to the quality of discussions
documented.
In summary, enrollees in a managed Medicare program for
nursing home residents were more likely to have advance
directives documented than typically reported for nursing
home residents, and an intervention to increase documentation of advance directive discussions was effective in further
increasing this rate. Geographical differences in patient desires for CPR and hospitalization existed before the intervention, and persisted after it. Future studies should examine the
barriers that health care providers face in discussing advance
directives with patients, and attempt to explain the reason for
the regional differences in the desire for CPR and
hospitalization.

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JAMDA – May 2001

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Navajo mother and daughter. Chinle, Arizona,
Jeffrey M. Levine, MD, photographer.

ORIGINAL STUDIES

DeLaGarza et al. 109

