Search

Adolescent disclosure to parents is a key aspect of positive parent-adolescent relationships and youth adjustment. We leveraged a study of diverse families with an adolescent with type 1 diabetes to examine how observed parental empathy during parent-adolescent conflict discussions about diabetes management was associated with observed adolescent disclosure and adolescent self-reported disclosure to parents. Adolescents with type 1 diabetes and the parent most involved in their diabetes care (N = 67 dyads) participated in the study. Parent empathy, adolescent disclosure, and parent positive affect during parent-adolescent conversations were rated by trained coders. Parents reported on their own empathy and adolescents reported on their own disclosure, parental knowledge of their diabetes management, and parental acceptance. Results indicated that observed parental empathy was associated with both observed and self-reported disclosure. This association remained after covarying other parent-adolescent relationship and parent dispositional, demographic, and diabetes variables. This study holds implications for promoting greater parental communication of empathy to encourage adolescent disclosure in the context of chronic illness management. [ABSTRACT FROM AUTHOR]

Objective: The Integrative Health and Wellness Clinic (IHWC), established in 2019 at the San Francisco VA Health Care System, is an interdisciplinary clinic consisting of a medical provider, dietician, physical therapist, and psychologist trained in complementary and integrative health (CIH) following the VA Whole Health model of care. Veterans with complex chronic conditions seeking CIH and nonpharmacologic approaches are referred to the IHWC. This study evaluated the clinic's acceptability and feasibility among veteran patients and its preliminary impact on health and wellbeing, health-related goals, and use of CIH approaches. Methods: Mixed methods were used to assess patient-reported outcomes and experiences with the IHWC. Participants completed surveys administered at baseline and 6-months and a subset completed a qualitative interview. Pre- and post-scores were compared using t-tests and chi-square tests. Results: Thirty-five veterans completed baseline and 6-month follow up surveys. Of these, 13% were women; 24% < 50 years of age, and 44% identified as racial/ethnic minorities. Compared to baseline, at 6 months, there were significant (P <.05) improvements in overall health, physical health, perceived stress, and perceived helpfulness of clinicians in assisting with goal attainment; there was a trend toward improved mental health (P =.057). Interviews (n = 25) indicated satisfaction with the interdisciplinary clinical model, support of IHWC providers in goal attainment, and positive impact on physical and mental health. Areas for improvement included logistics related to scheduling of multiple IHWC providers and referrals to other CIH services. Conclusion: Results revealed significant improvement in important clinical domains and satisfaction with interprofessional IHWC clinic providers, but also opportunities to improve clinic processes and care coordination. An interdisciplinary clinic focused on CIH and Whole Health is a feasible and acceptable model of care for veterans with complex chronic health conditions in the VA healthcare system. [ABSTRACT FROM AUTHOR]

OBJECTIVES: 1) To assess continuity of care (CoC) within primary- care practices for children with asthma and autism spectrum disorder (ASD) compared to children without chronic conditions, and 2) to determine patient and clinical-care factors associated with CoC. METHODS: Retrospective cohort study of electronic health records from office visits of children <9 years, seen ≥4 times between 2015 and 2019 in 10 practices of a community-based primary health care network in California. Three cohorts were constructed: 1) Asthma: ≥2 visits with asthma visit diagnoses; 2) ASD: same method; 3) Controls: no chronic conditions. CoC, using Usual Provider of Care measure (range > 0-1), was calculated for 1) all visits (overall) and 2) well-care visits. Fractional regression models examined CoC adjusting for patient age, medical insurance, practice affiliation, and number of visits. RESULTS: Of 30,678 children, 1875 (6.1%) were classified with Asthma, 294 (1.0%) with ASD, and 15,465 (50.4%) as Controls. Overall CoC was lower for Asthma (Mean = 0.58, SD 0.21) and ASD (M = 0.57, SD = 0.20) than Controls (M = 0.66, SD = 0.21); differences in well-care CoC were minimal. In regression models, lower overall CoC was found for Asthma (aOR = 0.90, 95% CI, 0.85-0.94). Lower overall and well-care CoC were associated with public insurance (aOR = 0.77, CI, 0.74-0.81; aOR = 0.64, CI, 0.59-0.69). CONCLUSION: After accounting for patient and clinical-care factors, children with asthma, but not with ASD, in this primary- care network had significantly lower CoC compared to children without chronic conditions. Public insurance was the most prominent patient factor associated with low CoC, emphasizing the need to address disparities in CoC. [ABSTRACT FROM AUTHOR]

Background: As a means to provide safety for a population at great risk of harm through abandonment, every state in the United States now has laws and practices for the safe relinquishment of newborns and infants. However, there is no national database tracking the population of infants surrendered through such programmes, and few states monitor these numbers. The primary aim of this study was therefore to examine the descriptive characteristics of infants who have been safely surrendered in a large, socio‐economically diverse urban area. The secondary aim was to compare them with local population norms to determine whether differences exist and to begin exploring what implications such differences may have for the treatment provided to these infants. Methods: A retrospective cross‐sectional study was conducted among safely surrendered infants. Results: Over half of the infants had medical issues, and the majority of the infants were surrendered in communities characterized by low median income. Conclusions: Preliminary information highlights potential economic, social, and medical risk factors, suggesting that these infants may require increased monitoring and/or specialized care. [ABSTRACT FROM AUTHOR]

Objectives: The Open Source Wellness (OSW) model was designed to function as a behavioral pharmacy; an affordable, accessible delivery system for a universal experiential prescription: MOVE (physical activity), NOURISH (healthy meals), CONNECT (social support), and BE (stress reduction). This study evaluates the OSW model in a billable group medical visit (GMV) format in a federally qualified health center (FQHC). Intervention: Patients with behaviorally mediated conditions, including cardiovascular disease, diabetes, and depression, as well as poor social determinants of health, such as food insecurity, were prescribed participation in the OSW program by their medical team. Groups met for 2 h each week for 16 weeks to complete 30 min of socially engaging physical activity, 5 min of mindfulness meditation, a 10-min interactive, didactic health lesson, a 5-min nutrition lesson, and 60 min of small-group coaching over a plant-based meal. Paraprofessional health coaches worked with participants in small groups to provide support and create accountability to goals. In addition, participants received a $10 voucher to Food Farmacy, which provided free produce. Subjects: The sample consisted of 49 patients from the Hayward Wellness Center, an FQHC in Hayward, California. They were mostly women, 59.6%, and racially and ethnically diverse: 23.1% African American, 5.8% Asian, 26.9% Hispanic/Latino, 11.5% Pacific Islander, and 32.7% Caucasian. Participants averaged 59.1 years of age (SD = 10.6). Outcome measures: Blood pressure and weight were recorded weekly. Demographic and acute care utilization data were drawn from the electronic medical record. Self-report questionnaires assessed diet, exercise, and mood on a monthly basis. Methods and results: Longitudinal data were analyzed with linear mixed models. Participants (n = 49) demonstrated significant increases in daily servings of fruits and vegetables, b = 0.31, p < 0.01, and exercise, b = 11.50, p < 0.01, as well as significant reductions in body mass index, b = −0.10, p = 0.05. Acute care utilization decrease was not statistically significant, b = −0.07, p = 0.14. Depressed patients (n = 11) saw reductions in depression, b = −1.72, p < 0.01, and hypertensive patients (n = 24) saw reductions in systolic blood pressure, b = −4.04, p < 0.01, but not diastolic blood pressure, b = 0.04, p = 0.95. Conclusions: This study demonstrates the effectiveness of the OSW behavioral pharmacy model within a GMV context; pathways for adaptation, spread/scale, and incorporation of this work as a component of the broader health ecosystem and national commitment to health equity are discussed. [ABSTRACT FROM AUTHOR]

Purpose To describe the development of a collaborative community–academic postgraduate year 1 pharmacy residency program in San Diego that provides a hybrid experience of opportunities in community practice, ambulatory care, and teaching. Summary Residency training programs are being developed to better match the evolving role of the community pharmacist. In 2016, the University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences partnered with Ralphs Pharmacy, a division of the Kroger Co. to launch a 1-year community residency to develop community-based pharmacists with diverse patient care, leadership, and education skills. Learning experiences include pharmacy operations, clinical services focusing on chronic disease management and education, teaching, and practice-based research. Training settings include community pharmacy, corporate pharmacy, ambulatory care, and academia. Graduates are prepared to work in these settings as well as capitalize on advanced training opportunities, including postgraduate year 2 residencies and professional certifications. The program has been successfully accredited, and graduates have completed the program: one completed a postgraduate year 2 residency, and both have obtained a management or clinical pharmacist position. Conclusion An innovative community—academic residency program preparing postgraduate year 1 learners for careers in community-based pharmacy, corporate, ambulatory care, and academic settings was developed, with positive preliminary outcomes. [ABSTRACT FROM AUTHOR]

Abstract This study explores the association between social support and chronic disease self-management among older adults of Mexican heritage who live in the U.S. and Mexico. We hypothesize that social support increases the ability to manage hypertension and Type 2 (T2) diabetes, regardless of place of residence. We also investigate if differences in country of residence and health system factors influence the ability to manage chronic conditions. Older adults 65 years or older from Los Angeles (LA) and Mexico City (CDMX), with diagnosed hypertension or T2 diabetes (self-reported), attending government agencies, participated in the study. The statistical analyses investigate differences between older adults in LA and CDMX; identify the association between social support and chronic disease self-management; and examine the role of T2 diabetes treatment, testing and complications on self-management. Our study findings show that social support was a statistically significant predictor of improved T2 diabetes self-management (37%–51%, p < 0.05). The association between social support and hypertension self-management was only significant (90% confidence level) for adherence to weight management and increased alcohol consumption. Our study did not identify statistically significant differences in social support between LA and CDMX. However, almost 40% of sampled older adults were at risk of social isolation, signaling a vulnerable population that needs to be targeted by health and social systems in the U.S. and Mexico. Our study also shows that social support is a strong predictor of improved T2 diabetes management in the U.S. and Mexico. While older adults in the U.S. and Mexico reported similar access to care and health insurance coverage, higher adherence to low salt diets in LA and reduced coverage of glucose testing in CDMX could signal areas of opportunity for policymakers. Health care providers in both countries need to identify ways of improving adherence to physical activity and weight management. Highlights • Almost 40% of sampled older adults were at risk of social isolation in both cities. • Social support was a significant predictor of improved T2 diabetes self-management. • Gender and age differences in diagnosed hypertension and T2 diabetes in both cities. • Increased adherence to low salt diets in Los Angeles. • Glucose testing and foot care were key differences in T2 diabetes self-management. [ABSTRACT FROM AUTHOR]

Objectives: Multimorbidity is common, but often poorly managed, among the rapidly growing population of older adults. The existing guidelines followed by physicians frequently lead to polypharmacy and a complex treatment burden. The objective of this study was to explore what benefits are perceived by older adults with multimorbidity as a result of long-term, regular acupuncture treatment. Design: A qualitative design with inductive thematic analysis of semistructured interviews. Settings/Location: Participants were recruited from a no-cost, college-affiliated acupuncture clinic for low-income older adults in an urban, racially/ethnically diverse neighborhood in southern California. Participants: Fifteen patients aged 60 years and older suffering from at least two chronic conditions. Results: Five themes were identified: (1) mind-body effects, (2) the enhanced therapeutic alliance, (3) what they liked best, (4) the conventional healthcare system, and (5) importance of regular schedule. A notable mind-body effect, reported by a substantial number of participants, was medication reduction. Participants also cited changes in mood, energy, and well-being as important benefits. In addition, they voiced widespread dissatisfaction with conventional healthcare. Keeping up regular treatments as a way to deal with new complaints and encourage a healthier lifestyle was seen an important aspect of care at the clinic. Conclusions: This cohort of older adults with multimorbidity valued acupuncture as a way to reduce medication as well as a means to maintain physical and mental health. In addition, they developed a strong trust in the clinic's ability to support the totality of their health as individuals, which they contrasted to the specialized and impersonal approach of the conventional medical clinic. [ABSTRACT FROM AUTHOR]

The Affordable Care Act expanded health insurance for low- income, uninsured individuals. Few longitudinal analyses have investigated how insurance expansion influences cost and utilization among adults with chronic conditions. This study conducted longitudinal analysis investigating time trends in utilization and cost among newly insured, chronically ill, low- income individuals using Generalized Estimating Equations models. For hospitalization, hospital outpatient services, emergency department (ED) visits, and primary care visits, two indicators were measured: the proportion of enrollees with services and the average number of visits among users. The average health expenditure per person was estimated using a gamma distribution. Results indicate that the number of individuals using inpatient or ED services was highest during the first six months following insurance coverage and decreased in subsequent periods, while primary care visits increased during the first year. Using six- month rather than annual measures of utilization and cost may be necessary to identify short- run changes following initial insurance coverage. [ABSTRACT FROM AUTHOR]

Most chronic illness management occurs outside clinics and hospitals, in the everyday lives of individuals. We use data from semi-structured interviews with 37 veterans from Southeastern Louisiana and Northern California to illustrate how "health work" for mental health concerns are shaped by place. Using health work as an orienting concept for analysis, we discerned variation between the two study sites in how Veterans used interacting with the natural environment, cultivating time alone, and religious practice to manage their mental health and well-being. Through these findings, we advocate for a situated notion of health work that is mindful of how health-related behaviors are shaped by place and the attributes that constitute place. [ABSTRACT FROM AUTHOR]

Background: Team-based chronic care models have not been widely adopted in community settings, partly due to their varying effectiveness in randomized control trials, implementation challenges, and concerns about physician acceptance. The Palo Alto Medical Foundation designed and implemented "Champion," a novel team-based model that includes new standard work (e.g. proactive patient outreach, pre-visit schedule grooming, depression screening, care planning, health coaching) to support patients' self-management of hypertension and diabetes. We investigated whether Champion improved clinical outcomes.Methods: We conducted a quasi-experimental study comparing the Champion clinic-level intervention (n = 38 physicians) with a usual care clinic (n = 37 physicians) in Northern California. The primary outcomes, blood pressure and glycohemoglobin (A1c), were analyzed using a piecewise linear growth curve model for patients exposed to a Champion physician visit (n = 3156) or usual care visit (n = 8034) in the two years prior and one year post implementation. Secondary outcomes were provider experience, compared at baseline and 12 months in both the intervention and usual care clinics using multi-level ordered logistic modeling, and electronic health record based fidelity measures.Results: Compared to usual care, in the first 6 months after a Champion physician visit, diabetes patients aged 18-75 experienced an additional -1.13 mm Hg (95% CI: -2.23 to -0.04) decline in diastolic blood pressure and -0.47 (95% CI: -0.61 to -0.33) decline in A1c. There were no additional improvements in blood pressure or A1c 6 to 12 months post physician visit. At 12 months, Champion physicians reported improved experience with managing chronic care patients in 6 of 7 survey items (p < 0.05), but compared to usual, this difference was only statistically significant for one item (p < 0.05). Fidelity to standard work was uneven; depression screening was the most commonly documented element (85% of patients), while care plans were the least (30.8% of patients).Conclusions: Champion standard work improved glycemic control over the first 6 months and physicians' experience with managing chronic care; changes in blood pressure were not clinically meaningful. Our results suggest the need to understand the relationship between the intervention, the contextual features of implementation, and fidelity to further improve chronic disease outcomes. This study was retrospectively registered with the ISRCTN Registry on March 15, 2017 (ISRCTN11341906). [ABSTRACT FROM AUTHOR]

This study uses the data set from Kaiser Permanente to examine the post implementation of a preventive and chronic care that utilizes clinical information system, delivery system design, and clinical decision support to maximize the office visit. The analysis suggests a significant positive relationship between frequency of utilization rates to address preventive and chronic care gaps. There is no implication of a significant positive relationship with the successfully captured rate, which satisfies closing the care gap within 45 days. The use of the preventive care tool will assist members in satisfying the preventive care gap, cervical cancer screening, within 45 days of the encounter. [ABSTRACT FROM AUTHOR]

Latino adults between ages 50 and 60 yr are at high risk for developing chronic conditions that can lead to early disability. We conducted a qualitative pilot study with 11 Latinos in this demographic group to develop a foundational schema for the design of health promotion programs that could be implemented by occupational therapy practitioners in primary care settings for this population. One-on-one interviews addressing routines and activities, health management, and health care utilization were conducted, audiotaped, and transcribed. Results of a content analysis of the qualitative data revealed the following six domains of most concern: Weight Management; Disease Management; Mental Health and Well-Being; Personal Finances; Family, Friends, and Community; and Stress Management. A typology of perceived health-actualizing strategies was derived for each domain. This schema can be used by occupational therapy practitioners to inform the development of health-promotion lifestyle interventions designed specifically for late-middle-aged Latinos. [ABSTRACT FROM AUTHOR]

Teachers and school nurses partner together to help ensure students stay healthy and engaged in school. The purpose of this study is to generate a deeper understanding of teachers’ perceptions on the benefits and challenges of working with full- or part-time school nurses. We conducted a qualitative analysis of open-ended survey responses from 129 teachers in nine low-income, ethnically diverse urban schools. These schools were part of a multiyear project that placed full-time nurses in four schools, while five schools with part-time nurses were used as a comparison group. Findings indicate that teachers had strong appreciation for the wide range of responsibilities undertaken by the school nurse. Teachers’ level of satisfaction was linked to the number of hours the nurse is on-site, where teachers reported greater satisfaction with nurses who worked on campus full time. Results point to factors that may improve working relations between teachers and nurses. [ABSTRACT FROM PUBLISHER]

Context: To meet demands for evidence-based chronic and preventive services and to improve performance, primary care practices are turning toward team-based strategies such as panel management, in which nonclinicians address routine preventive and chronic disease care tasks for a group of patients. No known validated instruments have been published for measuring panel management implementation. Objective: To describe development and evaluation of the Panel Management Questionnaire (PMQ), a self-report tool measuring panel management capability in primary care. Design: Cross-sectional study for questionnaire validation. Main Outcome Measures: We developed the 12-item PMQ from a conceptual framework to measure 4 domains of panel management and tested the questionnaire for internal and external validity. Data were assembled from self-administered cross-sectional surveys that included the PMQ instrument sent from February 2012 through May 2012. We surveyed 136 staff and 204 clinicians in 9 county and 5 university adult primary care clinics. Additional data came from clinic quality measures routinely collected the quarter before the survey. Results: The PMQ scale demonstrated good internal consistency (Cronbach α = 0.92 and 0.84 for staff and clinicians, respectively). Staff and clinician PMQ scores in each clinic were correlated (Kendall τ = 0.45, p < 0.05). The cliniclevel median PMQ score was positively associated with a composite clinic quality measure (Kendall τ = 0.42 for staff, 0.28 for clinicians). Conclusions: The PMQ measures self-reported panel management capability and may be a useful assessment and research tool for panel management implementation in primary care practice. [ABSTRACT FROM AUTHOR]

Safety-net hospitals are resource-constrained and serve complex patients yet are innovators in chronic disease care. Their strategies include personalized care, multidisciplinary teams, and information systems yielding real-time data. Safety-net providers are prime examples from which the health care community can learn to improve the delivery of chronic disease care. [ABSTRACT FROM AUTHOR]

Chronic Granulomatous Disease (CGD), a primary immunodeficiency disease (PID), is a rare genetic recessive mutation affecting one of 200,000 people worldwide. CGD impairs phagocytic NADPH oxidase activity in neutrophils resulting in granulomas or "walls" surrounding infections and chronic inflammation. Patients experience recurring life-long bacterial, fungal, and yeast infections of varying severity in the lungs, skin, bones, and lymph nodes, in addition to pain and shortened life expectancy. Compounding the disease are psychosocial issues (anxiety and depression) which can affect adherence and quality of life. This case study presents a 27-year-old woman with autosomal recessive p47phox-deficient CGD, diagnosed at age 12. It provides the perspective of the clinical research nurse (CRN), whose role affords unique glimpses of the ever-changing continuum of patient care, acute physical and mental health conditions, and evolving wishes. In February 2021, the patient enrolled in a research protocol to receive a high dose peripheral blood stem cell transplantation (PBSCT) from a 10/10 matched unrelated donor (MUD). She received a reduced conditioning regimen followed by post-transplant immunosuppressants to reduce graft versus host disease (GvHD). Her past medical history included liver abscesses, irritable bowel syndrome (IBS), osteoporosis, thrombosis, nonhealing wounds, chronic pain, nausea and vomiting, and migraines. During the transplant protocol, she also exhibited anxiety, depression, sleep disturbances, and eventually mucositis. Her anxiety manifested as hypervigilance and reactivity to downward trends of her medical conditions. Increasing anxiety affected her sleep and pain management, contributing to an overall negative emotional state that ultimately impaired treatment adherence. Attentive nursing care offered numerous opportunities to contribute to a successful outcome. For example, treatment required careful monitoring for infections, including sepsis, osteomyelitis, pneumonia, meningitis, and brain abscess. Additionally, the nurse could maximize compliance to the protocol regimen by providing psychosocial support and advocating for effective pain and mental health management. Identifying and maintaining the proper balance between protocol compliance and patient advocacy enabled the CRN to reduce the distress that could overload the patient's psychosocial condition and promote her improvement. As often, effective therapeutic communication to address concerns and minimize stress and anxiety contributed to a timely discharge by providing the patient a safe space for open communication and the opportunity to participate in her own care. [ABSTRACT FROM AUTHOR]

Objective To assess the relationship between clinical care metrics and patient experiences of care among patients with chronic disease. Design Cross-sectional survey and clinical performance data. Setting Eighty-nine medical groups across California caring for patients with chronic disease. Participants Using patient surveys, we identified 51 129 patients with a chronic disease. Main Outcome Measures Using patient surveys, we produced five composite measures of patient experiences of care and self-management support (scale 0–100). Using Health Plan Employer Data and Information Set data, we analyzed care for asthma, diabetes and cardiovascular disease, producing one composite summarizing clinical processes of care and one composite summarizing outcomes of care. We calculated adjusted Spearman's correlation coefficients to assess the relationship between patient experiences of care, clinical processes and clinical outcomes. Results Clinical performance was higher for process measures compared with outcomes measures, ranging from 91% for appropriate asthma medication use to 59% for controlling low-density lipoprotein cholesterol in the presence of diabetes. Performance on patient experiences of care measures was the highest for the quality of clinical interactions (88.5) and the lowest for delivery of self-management support (68.8). Three of the 10 patient experience–clinical performance composite correlations were statistically significant. These three correlations involved composites summarizing integration of care and quality of clinical interactions, and ranged from a low of 0.30 to a high of 0.39. Conclusions Chronic care delivery is variable across diseases and domains of care. Improving care integration processes and communication between health-care providers and their patients may lead to improved clinical outcomes. [ABSTRACT FROM AUTHOR]

The chronic care model (CCM) deployed through a learning collaborative strategy, such as the Institute for Healthcare Improvement’s Breakthrough Series (BTS), is a widely adopted approach to improve care that has guided clinical quality initiatives nationally and internationally. The BTS collaborative approach has been used to improve chronic conditions at national and state levels and in single health care delivery systems but not in correctional health care. Combining the CCM with a learning collaborative strategy in prison health care is a new frontier. This article describes the adoption of the CCM using a learning collaborative approach in the California prison system under the mandate of a federal receivership and elucidates some barriers to implementation. Results from the first phase of a pilot study were positive in terms of benefit/ cost analysis and suggest financial and political viability to continue the program. [ABSTRACT FROM AUTHOR]

Chronic disease management is becoming increasingly important in correctional settings, especially diabetes. We conducted a retrospective chart review of diabetic inmates in San Francisco County Jail and examined the sociodemographic characteristics, markers of disease status, and compliance with jail-specific care guidelines within this setting. We found high rates of compliance with immediate-term care guidelines (e.g., finger-stick glucose and blood pressure checks at intake) but less success in providing the more complex care required for chronic diseases. Inmates' age, race, and gender did not affect likelihood of meeting guidelines. (Am J Public Health. 2006;96:1571-1574. doi:10.2105/AJPH.20u4.056119) [ABSTRACT FROM AUTHOR]

Background: Advance care planning (ACP) is a process whereby patients prepare for medical decision-making. The traditional objective of ACP has focused on the completion of advance directives. We have developed a new paradigm of ACP focused on preparing patients and their loved ones for communication and informed medical decision-making. To operationalize this new paradigm of ACP, we created an interactive, patient-centered website called PREPARE ( www.prepareforyourcare.org ) designed for diverse older adults.Methods/design: This randomized controlled trial with blinded outcome assessment is designed to determine the efficacy of PREPARE to engage older Veterans in the ACP process. Veterans who are ≥ 60 years of age, have ≥ two medical conditions, and have seen a primary care physician ≥ two times in the last year are being randomized to one of two study arms. The PREPARE study arm reviews the PREPARE website and an easy-to-read advance directive. The control arm only reviews the advance directive. The primary outcome is documentation of an advance directive and ACP discussions. Other clinically important outcomes using validated surveys include ACP behavior change process measures (knowledge, contemplation, self-efficacy, and readiness) and a full range of ACP action measures (identifying a surrogate, identifying values and goals, choosing leeway or flexibility for the surrogate, communicating with clinicians and surrogates, and documenting one's wishes). We will also assess satisfaction with decision-making and Veteran activation within primary care visits by direct audio recording. To examine the outcomes at 1 week, 3 months, and 6 months between the two study arms, we will use mixed effects linear, Poisson, or negative binomial regression and mixed effects logistic regression.Discussion: This study will determine whether PREPARE increases advance directive completion rates and engagement with the ACP process. If PREPARE is efficacious, it could prove to be an easy and effective intervention to help older adults engage in the ACP process within or outside of the medical environment. PREPARE may also help older adults communicate their medical wishes and goals to their loved ones and clinicians, improve medical decision-making, and ensure their wishes are honored over the life course.Trial Registration: ClinicalTrials.gov NCT01550731 . Registered on 8 December 2011. [ABSTRACT FROM AUTHOR]