JAAPA Podcast Episode Summary

Episode Title: PA-led Telemedicine ACP Intervention
Date: April 10, 2025
Host: JAAPA
Guest: Krista Cooper, PhD, PA

Overview

This episode explores the impact and feasibility of a Physician Assistant (PA)-led telemedicine intervention for Advance Care Planning (ACP) in patients with life-limiting illness, particularly within a Huntington’s Disease clinic. Host(s) interview Krista Cooper, the lead author of a recently published research study, who shares her experiences, methodology, findings, and the implications for future PA-led ACP work.

Key Discussion Points & Insights

Importance of Advance Care Planning (ACP)

• ACP is critical for aligning care with patient preferences, reducing surrogate decision-making burdens, improving end-of-life care quality, enhancing communication, and potentially reducing healthcare costs.
• The lack of ACP discussions and documentation can have a significant negative impact on patients and families, especially in rare, progressive conditions such as Huntington’s Disease.
  • “I saw the struggles that their family went through when they were towards the end of life with decision making, not knowing if they are making the correct decisions for their loved one and more importantly, even having to go through the guardianship process.”
    — Krista Cooper [02:37]

Study Setting & Methodology

• Setting: Academic outpatient Huntington’s Disease Center of Excellence.
• Study Type: Randomized controlled trial (RCT) with optional open-label crossover.
• Participants: Patient-caregiver dyads (pairs) enrolled together.
• Intervention:
  • Compared PA-led telemedicine ACP visit to “typical care,” which consisted mainly of providing ACP documents (POA, Five Wishes forms) to complete at home.
  • After two weeks, the typical care group had the option to cross over to the telemedicine intervention.
  • Measurements:
    • Engagement: ACP engagement survey.
    • Feasibility: Successful completion of telemedicine visits.
    • Acceptability: Telehealth Usability Questionnaire.
  • Baseline review found poor typical engagement/documentation rates (24% had ACP discussions noted, only 10% had documents in EMR).
  • “I saw there was a really big need and our typical care was really failing our patient population.”
    — Krista Cooper [05:54]

Recruitment & Participant Perspective

• Recruitment was straightforward; nearly everyone invited agreed, often because they had already been wanting to have these conversations—underscoring unmet demand.
  • “I think nearly everyone I invited to participate agreed…this gives us an opportunity.”
    — Krista Cooper [08:08]

Outcomes & The PA’s Role

• Three main outcome measures:
  1. Engagement in ACP (using a validated survey)
  2. Feasibility (whether the tele-ACP visits occurred smoothly)
  3. Acceptability (patient/caregiver satisfaction via questionnaire)
• All conversations conducted by Krista Cooper, PA with >10 years’ experience and formal palliative medicine training.
  • She already had a trusted relationship with most participants, which likely enhanced outcomes.

High Satisfaction & Keys to Success

• 100% of participants were satisfied or highly satisfied with the telemedicine ACP experience; 96% were comfortable communicating over telehealth.
• Success likely due to:
  • Established rapport and trust.
  • The PA’s experience, compassion, and ability to conduct unrushed, empathetic conversations.
  • Averaged 45-minute visits, often completing paperwork and discussions in one session.
  • “I really tried to use nurse statements to provide empathy…naming emotions, providing understanding, respect, support… I also was not rushed.”
    — Krista Cooper [11:45]

Operationalizing PA-Led Telemedicine ACP

• The telemedicine approach is easily adaptable; most clinics already have telehealth infrastructure.
• Scheduling and conducting these sessions can fit within existing clinical workflows. Visits could be split into two shorter sessions (discussion + paperwork) if needed.
• Billing:
  • There are specific reimbursement codes for ACP—PAs should discuss billing options with administrators.
  • “There are reimbursement codes as well for advance care planning discussions…you should be billing for your time.”
    — Krista Cooper [13:53]
• Essential factors for success beyond time and billing:
  1. PA’s comfort and training in having end-of-life discussions.
  2. Disease-specific knowledge (especially for conditions like Huntington’s where timing of ACP is urgent).
  3. Understanding that patient/caregiver burden (travel, time, logistics) should be minimized.

Applicability & Implications for the PA Profession

• The intervention is highly adaptable to other clinics/disease settings.
• Empowers PAs: Demonstrates that PAs can autonomously and competently lead sensitive ACP discussions, enhancing their role in palliative medicine teams.
  • “PAs really can have a [breadth] of medical knowledge… time in their schedule, and the empathy that’s really required to have these types of emotional end of life discussions.”
    — Krista Cooper [17:23]
• Streamlines patient access to ACP, reducing barriers and potentially improving outcomes.

Notable Quotes & Memorable Moments

• “I think nearly everyone I invited to participate agreed to participate. And often I heard, ‘Oh great, we’ve been meaning to do this, I’ve been wanting to have these conversations and this gives us an opportunity.’”
  — Krista Cooper [08:08]

• “I also was not rushed, so I could kind of give them just time to discuss…I had a whole discussion with the dyad and we also completed healthcare power of attorney paperwork.”
  — Krista Cooper [11:45]

• “I do. I think it is really simple to implement at this point in the healthcare landscape. Probably most clinics have already implemented telemedicine and use telemedicine visits. So it would be kind of a similar scheduling process.”
  — Krista Cooper [13:10]

• “They’re not easy discussions to have…being comfortable framing these conversations in a way that is just supportive and just providing total care of the patient, including thinking ahead to end of life, is important.”
  — Krista Cooper [15:07]

• “…I really, really was wanting to make an intervention that would be very easily adaptable to different patient populations and very feasible. I didn’t want it to be a burden on patients and caregivers.”
  — Krista Cooper [18:17]

Timestamps for Key Segments

• Introduction to ACP & Study
  [00:24–02:07]
• Krista’s Background & Motivation
  [02:07–03:51]
• Study Setting and Methodology
  [04:50–07:37]
• Recruitment Success
  [08:07–08:42]
• Outcome Measures & PA Qualifications
  [08:55–10:52]
• Participant Satisfaction and Factors
  [10:52–12:54]
• Implementation in Other Settings
  [12:54–14:49]
• Barriers and Implementation Tips
  [15:02–16:50]
• PA Role & Future of Tele-ACP
  [16:50–18:09]
• Final Thoughts
  [18:17–19:22]

Conclusion

This episode highlights how PA-led telemedicine interventions for ACP are both feasible and highly valued by patients and caregivers, especially in settings where chronic and life-limiting illnesses demand timely planning. Krista Cooper’s research demonstrates that such interventions, when led by skilled and compassionate PAs, can bridge gaps in care, reduce burden, and empower both providers and patients—pointing to a promising future for PA roles in palliative care.