Improving Advanced Care Planning has been a priority at MMP for the past several years, with specific emphasis on patients aged 65 and older. However, there continues to be a need to have Serious Illness Conversations (SIC) with our most at risk patients to ensure quality of life (QOL) that supports the patients goals and values.

Goal: Supporting concordant care and improving the quality of end of life experience, providers strive to engage patients with advanced chronic disease in serious illness conversations. We will focus on increasing the frequency of these conversations at MMP Scarborough Primary Care, with the goals of ensuring that: i.The surprise question will be documented in Epic for > 50% of the patients identified as high risk by Care Management. ii.There will be documentation in Epic of a serious illness conversation for > 25% of the patients for whom the answer to the surprise question was ‘no’.