Clinical Decision Support Tool

ACP-Equity Risk Index

AI-augmented tool for equity-focused advance care planning. Identifies barriers to ACP completion and generates tailored intervention guidance for African-American patients.

Edusa S, MD · SGMC Health, Valdosta, GA · v1.0 (2026)

Instructions: Check each item that applies to the patient. The tool will calculate a composite risk score, identify dominant barrier domains, and generate tailored ACP intervention recommendations with evidence-based conversation guidance.

Medical Trust

0 / 12

Patient expresses distrust of healthcare providers or institutions wt:3

Patient or family references historical medical mistreatment (e.g., Tuskegee) wt:2

Patient has experienced or reports racial discrimination in healthcare wt:3

Patient expresses concern that documented preferences may lead to undertreatment wt:2

Patient lacks a consistent, trusted primary care provider wt:2

Access & Structural Barriers

0 / 8

Patient is uninsured or underinsured wt:2

Patient reports transportation barriers to healthcare wt:2

Patient resides in a rural or medically underserved area wt:1

Patient has limited access to specialist or palliative care services wt:2

Patient reports difficulty taking time off work for appointments wt:1

Cultural, Spiritual & Family Factors

0 / 6

Patient expresses strong religious or spiritual beliefs influencing healthcare decisions wt:1

Patient prefers family-centered (collective) decision-making over individual autonomy wt:1

Patient prefers conversational, warm communication over formal clinical style wt:1

Patient has not discussed end-of-life preferences with family members wt:2

Patient's cultural community has limited engagement with ACP programs wt:1

Clinical Complexity & Urgency

0 / 10

Patient has ≥2 chronic life-limiting conditions wt:2

Patient has been hospitalized ≥2 times in the past 12 months wt:2

Patient has no documented advance directive, healthcare proxy, or POLST wt:3

Patient has experienced a major health status change in past 6 months wt:2

Patient is age ≥65 years wt:1

Health Literacy & Communication

0 / 8

Patient has limited health literacy (difficulty understanding medical information) wt:2

Patient has limited English proficiency wt:2

Patient has not previously heard of or been offered advance care planning wt:2

Patient demonstrates knowledge gaps about prognosis or treatment options wt:1

Patient expresses confusion about the purpose of advance directives wt:1

0 items selected

0/44 LOWER RISK