Clinical trial · Interventional
UC Health Care Planning Study
Population-based Comparison of Evidence-based, Patient-centered Advance Care Planning Interventions on Advance Directive Completion, Goal Concordant Care and Caregiver Outcomes for Patients With Advanced Illness
- Source
- ClinicalTrials.gov
- Retrieved
- Sep 8, 2026
- Layer
- normalized (units and labels harmonized; values unchanged)
- Run
- ING-CLINICALTRIALS-20260908-000001
Summary
Brief summary (as posted)
Using a cluster randomized design at the clinic level, this project will implement and test three real-world, scalable advance care planning interventions among primary care clinics across three University of California health systems. Seriously ill patients identified using data from the electronic health record will receive (1) an advance directive with targeted messaging, (2) intervention 1 plus prompting to engage with the Prepare For Your Care website, or (3) intervention 2 plus engagement from a clinic-based facilitator. A Research cohort of patients will provide complete surveys at baseline, 12 and 24 months. The main outcomes are advance directive completion among the population cohort and goal concordant care among the Research cohort at 12 months.
Conditions
Conditions (3)
Free-text conditions as registered, with the CancerIndex entity they were reconciled to and the match type.
| Condition (as posted) | Mapped entity | Match | Confidence |
|---|---|---|---|
| Advance Care Planning | — | UNRESOLVED | — |
| Advanced Cancer | Malignant Neoplasm | CURATED_BROADER | 0.78 |
| Advance Directives | — | UNRESOLVED | — |
Interventions
Interventions (3)
| Intervention | Type | Mapped drug | Match |
|---|---|---|---|
| Advance directive | Behavioral | — | UNRESOLVED |
| Facilitator | Behavioral | — | UNRESOLVED |
| Prepare | Behavioral | — | UNRESOLVED |
Design
Arms and outcomes
Arms (3)
- type
- ACTIVE_COMPARATOR
- label
- Advance directive
- description
- Messaging and advance directive distribution. All arms receive physician advance care planning education at the clinic level.
- interventionNames
- Behavioral: Advance directive
- type
- ACTIVE_COMPARATOR
- label
- Advance directive and Prepare
- description
- Messaging and advance directive distribution plus introduction to the Prepare For Your Care website. All arms receive physician advance care planning education at the clinic level.
- interventionNames
- Behavioral: Advance directive
- Behavioral: Prepare
- type
- ACTIVE_COMPARATOR
- label
Eligibility
Eligibility (as posted)
- Sex
- All
- Minimum age
- 18 Years
Show eligibility criteria text
Population cohort Inclusion Criteria * At least 2 visits to a primary care clinic in the health system in the past 12 months * Serious illness according to an algorithm using electronic health record data including patients with: advanced cancer, advanced heart failure, advanced chronic obstructive pulmonary disease, decompensated liver disease, end stage renal disease, amyotrophic lateral sclerosis, or was a vulnerable elder with a serious illness Exclusion Criteria: None. Research cohort: Derived from the population cohort plus: Inclusion Criteria * Speak English or Spanish * Provide informed consent Exclusion Criteria * Too cognitively impaired to provide informed consent * Primary care physician identifies that survey may be harmful
References
Publications (3)
- BACKGROUNDWalling AM, Sudore RL, Bell D, Tseng CH, Ritchie C, Hays RD, Gibbs L, Rahimi M, Sanz J, Wenger NS. Population-Based Pragmatic Trial of Advance Care Planning in Primary Care in the University of California Health System. J Palliat Med. 2019 Sep;22(S1):72-81. doi: 10.1089/jpm.2019.0142. PMID 31486723
- DERIVEDWalling AM, Sudore RL, Gibbs L, Rahimi M, Hays RD, Tseng CH, Patel K, Santos K, Sanz Vidorreta FJ, Chau AJ, Antonio Lopez JC, Anand J, Marshall GR, DePaolis-Dickey A, Buen KI, Bell DS, Ritchie CS, Gonzalez V, Wenger NS. Interventions to Improve Advance Care Planning Documentation in the Electronic Health Record : A Cluster Randomized Trial. Ann Intern Med. 2026 Jan;179(1):42-50. doi: 10.7326/ANNALS-25-02111. Epub 2025 Nov 25. PMID 41285010
- DERIVEDHays RD, Walling AM, Sudore RL, Chau A, Wenger NS. Support for Use of Consumer Assessment of Healthcare Providers and Systems Communication Items Among Seriously Ill Patients. J Palliat Med. 2023 Sep;26(9):1234-1239. doi: 10.1089/jpm.2022.0572. Epub 2023 Apr 20. PMID 37093298