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Digital Advance Care Planning Reduces Costly Hospital Readmissions

Digital Advance Care Planning Reduces Costly Hospital Readmissions

Hospital systems often see patients numerous times as they near the end of life. This period of time can involve a flurry of healthcare appointments, treatments and interventions. In their last six months of life, Medicare beneficiaries go to the doctor’s office an average of 29 times. In their last month of life:

  • 50% of Medicare beneficiaries go to the emergency room
  • 33% wind up in an intensive care unit
  • 20% undergo surgery

These ER and ICU visits and procedures translate to Medicare spending for beneficiaries in the last year of life that is six times greater than the average. Every year Medicare spends 25-33% of its budget caring for Medicare beneficiaries who are near the end of life. Based on published research, we estimate this could have been as much as $225 billion in 2019.


Examining hospital readmissions

A sizable percentage of this spending results from repetitive hospital readmissions in the final year of a patient’s life, as doctors and nurses make heroic efforts to extend their life. The Centers for Medicare & Medicaid Services (CMS) defines readmissions as when, within 30 days of a hospital stay, a patient is admitted once again.

These readmissions often come with a high financial and emotional cost and they are uniquely tragic, because the overwhelming majority of these patients, if given a choice, would choose not to be hospitalized or receive life-sustaining medical interventions.

House-iconIn an October 2019 study by the California Health Care Foundation, it was found that among respondents, more than two-thirds (71%) said they would want to die at home. Yet, only a little over a third of Californians who died in 2017 did so at home (36%).

CheckboxMyDirectives users also have strong preferences regarding life-sustaining treatments and where they want to spend the end of their life. For example, almost 84% of MyDirectives users report that they would not want life-sustaining treatments if they suffered an irreversible brain injury that prohibited them from interacting with others and taking care of themselves.  Also, 78% of MyDirectives users with a digital ACP document report that they would prefer to spend their final days either at home or in a hospice facility, while only 4% say they would prefer to spend their final days in a hospital.

Lack of ACP document accessibility leads to diminished clarity

It’s not uncommon, over the course of providing care to patients, for hospital staff members and nurses to find themselves scrambling to determine whether those patients have ACP documents or any record of their wishes. What do they value? Who have they designated to make medical treatment decisions on their behalf?

Being able to seamlessly locate and retrieve an ACP document whenever and wherever it is needed means healthcare workers are more easily able to:

  • Provide the interventions the patient wants and values
  • Avoid interventions and treatments they don’t want
  • Avoid unwanted hospitalizations
  • Indisputably know who speaks for the patient


All too often, ACP documents (if they even exist) are locked away in a file cabinet or a safety deposit box, or they are stored with other important documents in a closet or under a bed. Sometimes only paper versions exist. If a digitized paper form is available, it might not provide the quality of information needed by medical personnel. 

Hospitals also face frequent uncertainty when attempting to discover which family or friends they should contact, how to contact them, or who is empowered to make decisions for a patient.

A 2007 review performed by Wilkinson, Wenger, and Shugarman found that amongst chronically ill nursing home residents — who rank among the most at-risk patients in the entire healthcare system — only 33% had any form of advance directive. This means that healthcare workers’ attempts to locate ACP documents are frequently fruitless.

COVID-19 further revealed the inadequacies and cost of a paper document-based advance directives approach.

Healthcare providers have a responsibility to provide their patients with better options. Yes, there may be a small, initial investment of time and resources required to properly implement a digital ACP process, but that action saves time later and decreases stress and uncertainty for everyone involved.

What does an effective digital ACP process look like?


Digital ACP documents empower individuals to share their goals, preferences and priorities, including what medical treatments they want (and don’t want), up front. Digital ACP documents also state who is allowed to make medical treatment decisions if a patient can’t speak for themselves, reducing misunderstandings and improving communications between medical staff and the patient’s family and loved ones.

Leveraging technology to improve ACP improves outcomes and patient experience while reducing health-related costs for high-risk, high-needs patients. But what makes this approach more effective than traditional ACP processes? A digital process means:

  • Flexibility: Individuals can undertake ACP on their own or with the assistance of medical professionals using MyDirectives for Clinicians™
  • Security: Cloud storage keeps documents stored safely and maintained in a secure off-site environment
  • Accessibility: Digital ACP documents are easily shared and retrieved whenever or wherever needed across the care continuum
  • Transparency: Extensive auditing and reporting features keep providers and payers engaged throughout the entire process

ADVault’s digital ACP solutions help patients, as well as the doctors and nurses caring for them, create high-quality ACP documents and portable medical orders such as POLST forms. Everything is stored securely in the cloud and ADVault uses internationally recognized standards to exchange data with hospital systems’ EHRs. This means the process of locating and retrieving those documents fits easily within current clinical workflows, regardless of the point of care. 


Disregarding ACP comes at a high cost

What does it look like when healthcare providers and their patients aren’t offered access to reliable and simple digital ACP options?

  • Continued strain on hospital systems and budgets caused by unnecessary and unwanted hospitalizations
  • Healthcare providers receive lower quality scores
  • Frontline staff bear the burden of searching for ACP documents during highly stressful emergency situations
  • More patients receive medical treatments and interventions of limited clinical value that they do not want
  • Doctors and nurses continue to be put in a position where they’re forced to perform unwanted treatments and interventions

Unfortunately, this happens multiple times every day across the nation, meaning patients and their families suffer through unnecessary levels of confusion and trauma.

Ensuring the best possible healthcare outcomes

Leveraging technology to improve ACP benefits healthcare systems, healthcare professionals, patients and their families. It enables healthcare professionals to conduct structured, meaningful conversations with patients about their wishes and preferences regarding treatment goals and location of care. It increases the likelihood that healthcare providers and families understand and comply with patients’ preferences when they cannot speak for themselves. And it reduces moral distress among critical care doctors and nurses.

Digital ACP results in more compassionate and humane end-of-life experiences for both patients and their families, improves the morale of the medical personnel who care for them and reduces unnecessary and unwanted hospitalizations and the associated high-cost, low-value medical interventions that accompany them.

Let’s get started on digital ACP together

Secure, Interoperable, Accessible.

MyDirectives offers the only digital advance care planning (ACP) tools and interoperable cloud-based storage that is HITRUST Risk-Based 2-year Certified.