Graduation Semester and Year
Fall 2026
Language
English
Document Type
DNP Project
Degree Name
Doctor of Nursing Practice
Department
Nursing
First Advisor
Cathy Brown, DNP, APRN, AGPCNP-BC, CNS
Second Advisor
Michelle Hampton, PhD, RN, NEA-BC
Abstract
Background
Medicare eligible individuals are less likely to have an advanced directive in place due to social isolation, lack of resources, lack of access to healthcare, and limited health literacy (Ambade et al., 2024; Perhach et al., 2023). On a national level, approximately 44% (114.4 million) of Americans have secured at least one form of a documented advanced directive (Ambade et al., 2024; Perumalswami et al., 2021). A clinic located in South Texas is below the state and national level for completed advance directives, at 18% (n=18).
Purpose
To evaluate the impact of a multi-modal Advance Care Plan (ACP) intervention among Medicare eligible individuals with at least two co-morbid conditions in a South Texas primary care clinic.
Methods
The John Hopkins Evidence-Based Practice Model framework was used to implement the multi-modal ACP intervention. The ACP intervention included video-assisted education led by nurses and providers including dyadic communication (patient and caregiver); culturally and linguistically tailored written material; documentation of care preferences, and a shared decision making tool titled Your Conversation Starter Guide.
Results
A Wilcoxon signed-rank test revealed a statistically significant increase in ACP completion following the intervention. The ACP rose from 18% (n=18) to 33% (n=35) post intervention, p=.001.
Conclusion and Implications for Practice
This multi-modal ACP intervention effectively increased ACP completion,
demonstrating that a clinical workflow redesign can overcome ACP health literacy and advance the delivery of value-based care.
Keywords
Advance Care Plan; Advance Care Planning; ACP; Advance Care Plan education; Advance Care Plan intervention; quality of life, care preferences
Disciplines
Family Practice Nursing | Geriatric Nursing | Other Nursing | Palliative Nursing
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
Recommended Citation
Garcia, Melissa, "Increasing Advance Directive Completion in Medicare Eligible Patients in South Texas Using A Multi-Modal Advanced Care Plan Intervention" (2026). Doctor of Nursing Practice (DNP) Scholarly Projects. 38.
https://mavmatrix.uta.edu/nursing_dnpprojects2/38
Included in
Family Practice Nursing Commons, Geriatric Nursing Commons, Other Nursing Commons, Palliative Nursing Commons