# PCplanner: operationalizing needs-focused palliative care for older adults in intensive

> **NIH NIH R01** · DUKE UNIVERSITY · 2020 · $537,136

## Abstract

The quality of intensive care unit (ICU)-based palliative care is highly variable, particularly for the 2 million
older adults admitted annually to ICUs. However, improving care quality on a broad scale with the
efficient delivery of patient-centered, need-targeted palliative care is challenging because of logistical and
technological barriers. To address these care delivery barriers among older ICU patients, we developed
a mobile app platform called PCplanner (Palliative Care planner). PCplanner automates the identification
of high-risk patients (e.g., dementia, declining health status, poor functioning) by directly capturing data
from electronic health record (EHR) systems, cultivates family engagement with supportive information
and a digital system for self-report of actual needs, and facilitates the delivery of care to those with a high
burden of need by coordinating collaboration between ICU teams and palliative care specialists. In pilot
comparison to a standard palliative care control, the intervention reduced unmet needs, psychological
distress, and length of stay and increased goal concordant care, communication, and hospice utilization.
 While these data are compelling, an efficacy evaluation of PCplanner is needed. Therefore, we
propose to enroll 250 patients, 270 family caregivers, and 215 physicians and nurses from academic and
community settings in a 5-year project with 3 aims: (1) Optimize the fully realized PCplanner platform’s
usability for older adults, (2) Test the efficacy of PCplanner-augmented collaborative palliative care vs
usual care in a randomized clinical trial (RCT) with 3-month follow up, and (3) Explore family caregiver
and clinician experiences using mixed methods to understand intervention mechanisms as well as
implementation barriers within diverse case contexts. We hypothesize that compared to usual care,
PCplanner will reduce family caregivers’ unmet needs and psychological distress, increase the frequency
of goal concordant treatment among older adult patients, and reduce hospital length of stay.
 PCplanner represents a potentially transformative, paradigm-changing approach to delivering scalable
personalized ICU-based palliative care for older adults: it acts as infrastructure for a replicable
collaborative care model, provides a state of the art technological build that enables real-time direct data
capture from any hospital’s EHR (i.e., interoperability), and automates the measurement of patient- /
family-centered outcomes and quality indicators—all areas that are lacking in current practice. This
theoretically grounded project’s numerous technological and conceptual innovations address research
priorities detailed by the NIH (Palliative Care Priorities Workgroup), the Office of the National Coordinator
(Connecting Health and Care for the Nation Roadmap), and the National Academy of Medicine (Vital
Directions for Health Care Services initiative). We can perform this research successfully because of our
mul...

## Key facts

- **NIH application ID:** 9891931
- **Project number:** 5R01AG058915-02
- **Recipient organization:** DUKE UNIVERSITY
- **Principal Investigator:** Christopher Ethan Cox
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $537,136
- **Award type:** 5
- **Project period:** 2019-03-15 → 2024-02-29

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9891931

## Citation

> US National Institutes of Health, RePORTER application 9891931, PCplanner: operationalizing needs-focused palliative care for older adults in intensive (5R01AG058915-02). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/9891931. Licensed CC0.

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