Serious Illness Care Community of Practice

The Serious Illness Care Community of Practice is a network of interdisciplinary teams working together to improve the lives of the seriously ill by increasing meaningful conversations with clinicians about their patient’s values and priorities. The Community of Practice will leverage the materials and methods developed in the Serious Illness Care Program, which is designed to support clinicians in conducting the right conversation, at the right time (in the outpatient setting, before a crisis), with the right people (patient and family) present or included, guided by the right clinician (the person who knows the patient and his/her medical situation best). Our patient-centered communication intervention creates a population management system to: 1) identify patients who would benefit from discussions of end-of-life preferences; 2) train and coach physicians and other clinicians to use a structured communication guide to elicit patient values and goals; 3) trigger clinicians to conduct conversations 4) facilitate patient communication with family members; and 5) document patients’ wishes in a “single source of truth” in the electronic medical record. Impact will be achieved through development and dissemination of a system that allows preferences for care that are communicated and followed across the care network.