# Mapping the Complex Processes and Outcomes of Care Planning

> **NIH NIH R01** · INDIANA UNIVERSITY INDIANAPOLIS · 2024 · $738,355

## Abstract

PROJECT SUMMARY/ABSTRACT
Advance care planning (ACP) supports patients in identifying and communicating their preferences for medical
care and is a key component of patient-centered care. The Patient Self Determination Act of 1990 narrowly
defined ACP as documentation of preferences for end-of-life procedures (e.g., resuscitation), resulting in a
focus on advance directive completion. Since then, ACP has evolved to include a focus on preparing patients
and caregivers for communication and decision-making across the illness trajectory, which is better
conceptualized as “Care Planning” (CP) because the process includes both advance and in-the-moment
decisions over the life course. While health systems have invested in CP as a requisite component of patient-
centered care and it is reimbursed by the Centers for Medicare and Medicaid Services, wide heterogeneity of
CP implementation and measurement remain, and the perspectives and needs of culturally diverse patients,
caregivers, and interdisciplinary key informants (e.g., nurses, attorneys, chaplains, etc.,) have not been
considered. Unprecedented basic science (NIH Stage Model, Stage 0) is required to map the complexity of the
entire CP process. Implementation science and human factors engineering offer a path towards clarity. This
proposal advances the field of CP and implementation science by leveraging diverse key informant
perspectives and human factors engineering methods to map implementation processes of CP and to identify
meaningful CP outcomes across clinical and community settings and illness trajectories. We will apply the well-
validated Consolidated Framework for Implementation Research (CFIR) model to illuminate CP’s complexity.
CFIR domains include CP innovation characteristics (e.g., discussions) that operate in an inner setting (e.g.,
inpatient, outpatient, nursing home, hospice) and outer setting (e.g., policy, faith communities) centered around
culturally and ethnically diverse interdisciplinary key informants (e.g., patients, caregivers, healthcare
professionals, community leaders, legal/policy experts) involving a range of implementation components (e.g.,
initiating, facilitating, documenting, storing, accessing, updating CP wishes). This complexity is amplified by
patients’ illness trajectories, healthcare access, and unique and differing cultural backgrounds. Our study aims
are to: 1) Define processes of CP for varying settings (community, outpatient, acute care, long-term care,
hospice), illness trajectories (healthy/chronic illness, serious illness, end-of-life), and healthcare access (rural,
public, under-resourced) by creating CP Workflow Archetypes; and 2) Identify patient/caregiver centered and
implementation outcomes for each component of the CP Workflow Archetypes. Using CFIR and human factors
engineering we will map essential implementation factors of CP through focus groups and interviews and use
Delphi methods to identify meaningful patient/caregiver centered outco...

## Key facts

- **NIH application ID:** 10882559
- **Project number:** 1R01NR020607-01A1
- **Recipient organization:** INDIANA UNIVERSITY INDIANAPOLIS
- **Principal Investigator:** SUSAN E HICKMAN
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2024
- **Award amount:** $738,355
- **Award type:** 1
- **Project period:** 2024-06-12 → 2029-03-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10882559

## Citation

> US National Institutes of Health, RePORTER application 10882559, Mapping the Complex Processes and Outcomes of Care Planning (1R01NR020607-01A1). Retrieved via AI Analytics 2026-05-26 from https://api.ai-analytics.org/grant/nih/10882559. Licensed CC0.

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