Automatic Patient Outreach May Be the Key to Improving Advance Care Planning for Seriously Ill Patients

Advance care planning, often shortened to ACP, plays a critical role in ensuring that people receive medical care aligned with their values and preferences when they face serious illness. Yet, despite its importance, many patients never complete the necessary documentation. New research from the University of California suggests that a relatively simple change — automatic outreach to patients, combined with personal assistance — could significantly improve how often advance care plans are completed and recorded.

The study, led by researchers from the University of California, Los Angeles, examined how different outreach strategies affected advance care planning among seriously ill patients. The findings indicate that when health systems take a more proactive role, especially by involving trained health navigators, patients are far more likely to complete advance directives and engage in meaningful conversations about their future medical care.

Why Advance Care Planning Matters

Advance care planning allows individuals to document their wishes about medical treatment in case they become unable to make decisions for themselves. These wishes are typically recorded in documents such as advance directives, POLST forms, or do-not-resuscitate (DNR) orders. When properly completed and stored in electronic health records, these documents help doctors and family members make decisions that respect a patient’s goals, values, and preferences.

Despite broad agreement among clinicians that ACP is essential, real-world completion rates remain low. Primary care physicians often struggle to initiate these conversations due to time constraints, competing medical priorities, and uncertainty about when and how to raise the topic. As a result, many patients only confront these decisions late in the course of illness — or not at all.

The Focus of the Study

To explore how health systems might better support advance care planning, researchers conducted a large clinical trial across three University of California health systems: UCLA, the University of California, San Francisco, and the University of California, Irvine.

The study included approximately 8,000 seriously ill patients. All participants met several criteria: they had a serious medical condition, an established primary care physician within one of the participating health systems, and at least two primary care visits in the previous year. Importantly, none of the patients had an advance directive or similar documentation already available in their electronic health record at the start of the study.

The researchers wanted to know which outreach strategy — or combination of strategies — was most effective at encouraging patients to complete advance care planning documentation within 12 months and 24 months.

Three Different Outreach Approaches

The study compared three distinct ACP interventions, each building on the previous one. All clinics involved in the study also provided their physicians with training on advance care planning, ensuring that clinicians were prepared to support these discussions.

First intervention:
Patients received an automated message through their electronic health record portal, along with a mailed letter. This communication explained why advance care planning is important and included clear steps for completing an advance directive. The goal was to prompt patients to reflect on their preferences and discuss them with their doctor.

Second intervention:
This group received everything included in the first intervention, plus access to PrepareForYourCare.org. This widely used online resource helps individuals think through medical decisions, learn about treatment options, and complete advance care planning documents with greater confidence.

Third intervention:
In addition to all the materials provided in the first two interventions, this group received direct outreach from a health navigator. Health navigators contacted patients ahead of their doctor visits to offer assistance, answer questions, and help guide them through advance care planning and document completion.

What the Researchers Found

After analyzing outcomes at the 24-month mark, clear differences emerged between the three groups.

• 13.7% of patients in the first group completed an advance directive that was available in the electronic health record.
• 12.7% of patients in the second group completed an advance directive.
• 19.8% of patients in the third group completed an advance directive.

The results showed that simply adding more information, such as an online decision aid, did not significantly increase completion rates compared to basic automated outreach alone. However, when personal support from a health navigator was added, the impact was substantial.

Patients who received navigator outreach were not only more likely to complete advance care planning documents, but they also had more documented advance care discussions in their medical records.

Why Health Navigators Make a Difference

Health navigators act as a bridge between patients and the healthcare system. They are trained to explain medical information in accessible language, help patients reflect on their values, and guide them through administrative steps that might otherwise feel overwhelming.

In the context of advance care planning, navigators can prepare patients before they even enter the exam room. This support allows physician visits to focus on meaningful conversations rather than paperwork and logistics. The study suggests that this human element — combined with automated systems — creates a powerful and scalable model for ACP engagement.

What the Study Did Not Show

While the findings are encouraging, the researchers were careful to note several limitations. The study was conducted entirely within University of California health systems, which may differ from community hospitals or smaller practices in terms of resources and patient populations. As a result, the findings may not fully apply to all healthcare settings.

Additionally, the trial did not include a traditional control group receiving usual care without intervention. Instead, all participants received some form of outreach. The study also did not measure whether the documented advance care plans ultimately led to goal-concordant care during serious illness, which remains an important area for future research.

The Broader Implications for Healthcare

This research highlights how system-level changes can support better patient outcomes without placing additional burden on physicians. Automated messaging, combined with targeted human support, fits naturally into existing clinical workflows and can be expanded across large health systems.

As populations age and chronic illness becomes more common, the need for effective advance care planning will only grow. Studies like this suggest that improving ACP completion is not just about encouraging patients to think ahead, but about designing healthcare systems that make those conversations easier, earlier, and more routine.

Understanding Advance Care Planning Beyond the Study

Advance care planning is not a one-time event. Preferences can evolve as health conditions change, and documents should be reviewed and updated regularly. Experts recommend revisiting ACP during major life events, new diagnoses, or significant changes in health status.

Electronic health records also play a crucial role. Even when patients complete advance directives, those documents are only useful if they are easily accessible to clinicians when decisions need to be made. Integrating ACP into EHR systems, as this study did, ensures that patient wishes are visible across care settings.

What Comes Next

The researchers involved in the study plan to expand this approach to broader patient populations and additional healthcare systems. By refining outreach strategies and exploring long-term outcomes, future research could further strengthen the role of advance care planning in patient-centered care.

Ultimately, the study reinforces a simple but powerful idea: when healthcare systems take the initiative and offer structured support, patients are more likely to engage in planning that can profoundly shape their care during life’s most critical moments.

Research reference:
Interventions to Improve Advance Care Planning Documentation in the Electronic Health Record, Annals of Internal Medicine (2025)
https://doi.org/10.7326/ANNALS-25-02111