Trial Outcomes & Findings for A Portal-based Advance Care Planning Intervention Among Community-Dwelling Persons Living With Cognitive Impairment (NCT NCT06509373)

Results Overview

Percentage of participants who open the advance care planning tool (ACPVoice) mychart message

Recruitment status

COMPLETED

Study phase

NA

Target enrollment

300 participants

Primary outcome timeframe

Up to month 6

Results posted on

2026-08-31

Participant Flow

Participant milestones

Participant milestones
Measure	ACPVoice Intervention Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health , have a primary care physician at one of the participating sites, and have an active patient portal account. Advance Care Planning Tool - ACPVoice: Eligible patients will be sent a secure MyChart message with a motivational message asking them to complete the advance care planning tool (ACPVoice) with their care partner/surrogate decision-maker or loved one before their upcoming primary care visit. The ACPVoice tool will be attached electronically to the mychart message. A reminder message will be sent to an non-responders with a different motivational message.	Standard of Care Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health, have a primary care physician within the Atrium-Wake Forest Baptist Health Network, and have an active patient portal account. Standard of Care for Advance Care Planning: Patients will have access to the standardized advance care planning questionnaires readily available already within their mychart account which is part of standard of care.
Overall Study STARTED	150	150
Overall Study COMPLETED	138	150
Overall Study NOT COMPLETED	12	0

Reasons for withdrawal

Reasons for withdrawal
Measure	ACPVoice Intervention Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health , have a primary care physician at one of the participating sites, and have an active patient portal account. Advance Care Planning Tool - ACPVoice: Eligible patients will be sent a secure MyChart message with a motivational message asking them to complete the advance care planning tool (ACPVoice) with their care partner/surrogate decision-maker or loved one before their upcoming primary care visit. The ACPVoice tool will be attached electronically to the mychart message. A reminder message will be sent to an non-responders with a different motivational message.	Standard of Care Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health, have a primary care physician within the Atrium-Wake Forest Baptist Health Network, and have an active patient portal account. Standard of Care for Advance Care Planning: Patients will have access to the standardized advance care planning questionnaires readily available already within their mychart account which is part of standard of care.
Overall Study progression of dementia	2	0
Overall Study transitioned to hospice	4	0
Overall Study Death	4	0
Overall Study reschedule PCP visit outside study window	2	0

Baseline Characteristics

A Portal-based Advance Care Planning Intervention Among Community-Dwelling Persons Living With Cognitive Impairment

Baseline characteristics by cohort

Baseline characteristics by cohort
Measure	ACPVoice Intervention n=150 Participants Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health , have a primary care physician at one of the participating sites, and have an active patient portal account. Advance Care Planning Tool - ACPVoice: Eligible patients will be sent a secure MyChart message with a motivational message asking them to complete the advance care planning tool (ACPVoice) with their care partner/surrogate decision-maker or loved one before their upcoming primary care visit. The ACPVoice tool will be attached electronically to the mychart message. A reminder message will be sent to an non-responders with a different motivational message.	Standard of Care n=150 Participants Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health, have a primary care physician within the Atrium-Wake Forest Baptist Health Network, and have an active patient portal account. Standard of Care for Advance Care Planning: Patients will have access to the standardized advance care planning questionnaires readily available already within their mychart account which is part of standard of care.	Total n=300 Participants Total of all reporting groups
Age, Continuous	80.53 years STANDARD_DEVIATION 8.36 • n=14 Participants	81.65 years STANDARD_DEVIATION 7.78 • n=36 Participants	81.09 years STANDARD_DEVIATION 8.07 • n=324 Participants
Sex: Female, Male Female	88 Participants n=14 Participants	97 Participants n=36 Participants	185 Participants n=324 Participants
Sex: Female, Male Male	62 Participants n=14 Participants	53 Participants n=36 Participants	115 Participants n=324 Participants
Ethnicity (NIH/OMB) Hispanic or Latino	1 Participants n=14 Participants	2 Participants n=36 Participants	3 Participants n=324 Participants
Ethnicity (NIH/OMB) Not Hispanic or Latino	149 Participants n=14 Participants	148 Participants n=36 Participants	297 Participants n=324 Participants
Ethnicity (NIH/OMB) Unknown or Not Reported	0 Participants n=14 Participants	0 Participants n=36 Participants	0 Participants n=324 Participants
Race (NIH/OMB) American Indian or Alaska Native	1 Participants n=14 Participants	0 Participants n=36 Participants	1 Participants n=324 Participants
Race (NIH/OMB) Asian	0 Participants n=14 Participants	2 Participants n=36 Participants	2 Participants n=324 Participants
Race (NIH/OMB) Native Hawaiian or Other Pacific Islander	0 Participants n=14 Participants	0 Participants n=36 Participants	0 Participants n=324 Participants
Race (NIH/OMB) Black or African American	13 Participants n=14 Participants	39 Participants n=36 Participants	52 Participants n=324 Participants
Race (NIH/OMB) White	135 Participants n=14 Participants	109 Participants n=36 Participants	244 Participants n=324 Participants
Race (NIH/OMB) More than one race	1 Participants n=14 Participants	0 Participants n=36 Participants	1 Participants n=324 Participants
Race (NIH/OMB) Unknown or Not Reported	0 Participants n=14 Participants	0 Participants n=36 Participants	0 Participants n=324 Participants

PRIMARY outcome

Timeframe: Up to month 6

Population: Standard of care participants had access to the usual Epic ACP tool but did not receive ACPVoice messaging or outreach.

Percentage of participants who open the advance care planning tool (ACPVoice) mychart message

Outcome measures

Outcome measures
Measure	ACPVoice Intervention n=138 Participants Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health , have a primary care physician at one of the participating sites, and have an active patient portal account. Advance Care Planning Tool - ACPVoice: Eligible patients will be sent a secure MyChart message with a motivational message asking them to complete the advance care planning tool (ACPVoice) with their care partner/surrogate decision-maker or loved one before their upcoming primary care visit. The ACPVoice tool will be attached electronically to the mychart message. A reminder message will be sent to an non-responders with a different motivational message.	Standard of Care Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health, have a primary care physician within the Atrium-Wake Forest Baptist Health Network, and have an active patient portal account. Standard of Care for Advance Care Planning: Patients will have access to the standardized advance care planning questionnaires readily available already within their mychart account which is part of standard of care.
Engagement Rate	68.8 percentage of participants	—

PRIMARY outcome

Timeframe: Up to month 6

In the ACPVoice arm, completion was defined as completion of the ACPVoice questionnaire following outreach through the patient portal and follow-up reminders. In the Standard of Care arm, completion was defined as completion of the standard Epic ACP questionnaire (ACP For My Care Team Questionnaire) available through the patient portal without additional prompting or outreach.

Outcome measures

Outcome measures
Measure	ACPVoice Intervention n=138 Participants Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health , have a primary care physician at one of the participating sites, and have an active patient portal account. Advance Care Planning Tool - ACPVoice: Eligible patients will be sent a secure MyChart message with a motivational message asking them to complete the advance care planning tool (ACPVoice) with their care partner/surrogate decision-maker or loved one before their upcoming primary care visit. The ACPVoice tool will be attached electronically to the mychart message. A reminder message will be sent to an non-responders with a different motivational message.	Standard of Care n=150 Participants Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health, have a primary care physician within the Atrium-Wake Forest Baptist Health Network, and have an active patient portal account. Standard of Care for Advance Care Planning: Patients will have access to the standardized advance care planning questionnaires readily available already within their mychart account which is part of standard of care.
Percentage of Intervention Completion	79 percentage of participants	0 percentage of participants

SECONDARY outcome

Timeframe: 12 months pre intervention, up to month 6 post intervention

Population: 12 participants in the ACPVoice arm did not complete the intervention

Number of participants with documentation of advance care planning within the electronic health record by primary care provider. Preintervention data collected from a chart review after participant enrolled in study.

Outcome measures

Outcome measures
Measure	ACPVoice Intervention n=150 Participants Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health , have a primary care physician at one of the participating sites, and have an active patient portal account. Advance Care Planning Tool - ACPVoice: Eligible patients will be sent a secure MyChart message with a motivational message asking them to complete the advance care planning tool (ACPVoice) with their care partner/surrogate decision-maker or loved one before their upcoming primary care visit. The ACPVoice tool will be attached electronically to the mychart message. A reminder message will be sent to an non-responders with a different motivational message.	Standard of Care n=150 Participants Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health, have a primary care physician within the Atrium-Wake Forest Baptist Health Network, and have an active patient portal account. Standard of Care for Advance Care Planning: Patients will have access to the standardized advance care planning questionnaires readily available already within their mychart account which is part of standard of care.
Advance Care Planning Documentation Rates by Primary Care Providers 12 months pre intervention	1 Participants	0 Participants
Advance Care Planning Documentation Rates by Primary Care Providers 6 months post intervention	70 Participants	0 Participants

SECONDARY outcome

Timeframe: 12 months pre intervention, up to month 6 post intervention

Population: 12 participants in the ACPVoice arm did not complete the intervention

Number of participants with advance care planning billing code usage (CPT codes 99497, 99498; HCPCS codes 1123, 1124). Data collected from a chart review after participant enrolled in study.

Outcome measures

Outcome measures
Measure	ACPVoice Intervention n=150 Participants Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health , have a primary care physician at one of the participating sites, and have an active patient portal account. Advance Care Planning Tool - ACPVoice: Eligible patients will be sent a secure MyChart message with a motivational message asking them to complete the advance care planning tool (ACPVoice) with their care partner/surrogate decision-maker or loved one before their upcoming primary care visit. The ACPVoice tool will be attached electronically to the mychart message. A reminder message will be sent to an non-responders with a different motivational message.	Standard of Care n=150 Participants Community-dwelling persons living with cognitive impairment aged 65 and older with known or probable mild cognitive impairment or dementia or elevated eRADAR score (with decision-making capacity), who are affiliated with the Atrium-Wake Forest Baptist Health, have a primary care physician within the Atrium-Wake Forest Baptist Health Network, and have an active patient portal account. Standard of Care for Advance Care Planning: Patients will have access to the standardized advance care planning questionnaires readily available already within their mychart account which is part of standard of care.
Rate of Advance Care Planning Billing Code Usage 12 months pre intervention	2 Participants	0 Participants
Rate of Advance Care Planning Billing Code Usage 6 months post intervention	42 Participants	0 Participants

SECONDARY outcome

Timeframe: 12 months pre intervention, month 6 post intervention

Population: 12 participants in the ACPVoice arm did not complete the intervention

Number of participants with a documented designated surrogate decision maker in the electronic health record. Data collected from a chart review after participant enrolled in study.